Progress Note Template

From Virtual Rounding

Progress Note

Interval Events: ***

Subjective: ***

Exam

@VSRANGES@

@IOBRIEF@

- Gen: NAD

- HEENT: MMM, PERRL, oropharynx non-erythematous, no cervical or supraclavicular LAD

- CV: RRR, no m/r/g, JVP ***

- Pulm: CTAB, no wheezes, rhonchi, or rales

- Abd: Soft, NTND, NABS, no rebound or guarding

- Ext/skin: WWP, no rashes, no edema

- Neuro: AOx3, CNII-XII intact, strength 5/5 and sensation intact to light touch in all extremities

Meds, Labs and Imaging reviewed in Epic and notably commented on below.

@FISHBONEBMP@

@FISHBONECBC@

Assessment

@BRIEFSUMMARY@

  1. ***: ***

Bundle

- DVT: {IP DVT PROPHYLAXIS IP:22062}

- FEN: ***

- K, Mg: ***

- Emergency contact: @RREMERCONTACT@

- @RRCODESTATUS@

Prepared with the assistance of [INSERT YOUR NAME HERE] via remote participation.