SMR On Call Notes. Created by P. Raut, PGY-2 IM Ottawa. Draft 1 Updated April 2012
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1 SMR n Call Notes Created by P. Raut, PGY-2 IM ttawa. Draft 1 Updated April 2012
2 SMR n Call Notes An Admission Note Template
3 Admission Note Template Identification Allergies Physicians What medications is this patient allergic to? What is their allergy to it? Who is this patient s family doctor? What other specialists follow this patient? Are there any upcoming appointments? Social History ADLs/IADLs Medications Group your medications into categories (cardiovascular meds, puffers, antibiotics, etc.) and, depending on your staff, you may wish to present them in your past medical history section (eg. atrial fibrillation on wafarin x 7 years). Past Medical & Surgical History History of Present Illness Review of Systems When presenting your admission to your senior or staff, organize your review of systems into cardiovascular, respiratory, gastrointestinal, infectious, constitutional categories and only name pertinent positives. Before proceeding to presenting your findings on physical examination, you can ask your staff if they want to any other information. This keeps your presentation concise and your admission note is thorough. Course in Hospital What medications have been given? How much IV fluids have been administered? Examination in ER Note any pertinent positive or negative findings as well as any changes from your own examination. Examination on Admission Investigations Bloodwork EKG Imaging Impression Plan What s the big picture? How do all of this patent s medical conditions contribute to his/her chief complaint? What are the acute/chronic issues that need to be addressed during this admission in order of importance? What is the cause? What is the consequence? How will you investigate and manage this? Start writing your admission orders while waiting to review with your senior resident. If your senior has already submitted the admission slip, complete the HPI section in the edischarge summary while waiting to review.
4 rganizing your information PMHx Diabetes Mellitus Type I or II? How many years? Followed by Dr. X Microvascular complications Retinopathy? Last eye exam? Nephropathy? Proteinuria? Last urine ACR? CKD? ESRD? HD? Neuropathy? Tonofilament testing? Gastroparesis? Macrovascular complications ACS? CVA? PVD? ther complications Diabetic foot care/ulcers? ther Infections? Cataracts? GDM/Pregnancy complications? Associated conditions Hypertension target < 130/80 Dyslipidemia besity Etc. Plan Diabetic Ketoacidosis Precipitated by: Current management ngoing investigations Medications being held Follow-up investigations or consults?
5 SMR n Call Notes Admission rders Template
6 Admit to MEA? MEB? MEC? AMA? Diagnosis MD Isolation ADMIT VITALS AND PHYSICAL EXAM Contact? Droplet? Airborne? Telemetry Parameters? Vital signs VSR is usually qshift Do you need neurovitals? IV access and IV fluids NS lock IV if euvolemic and DAT Will patient be NP and need maintenance? Is patient hypotensive and need central line? Therapists and allied health consults PT? T? Dietician? SLP? SW? Allergies Labs What kind of reaction did they have? What daily bloodwork do you need? What bloodwork do you repeat tonight? Studies Did you fill out requisitions for CT scan? U/S? Activity - Usually as tolerated. Fall risk? Nursing orders eg. Notify MD if SBP < 90 Diet Cardiac? Diabetic? NP for procedure? Full fluids? Minced? Peptic ulcer prophylaxis Heparin/VTE prophylaxis Is your patient ambulating? Yank Foley catheter if not needed Skin care Incentive spirometry? Calcium/Vit. D/bisphosphonate If steroid use/osteoporosis/# ACEi/ASA if Hx of CAD? Lipid panel ECG X-Rays eg. PA & lateral CXR if indicated. Advanced directives/goals of Care/Category Status Medication Reconciliation Parameters for BP meds?
7 SMR n Call Notes Key Pharmacology Review Points
8 Antibiotics Allergies? What organisms? What infectious process? Who is your host? Immunocompromised? Renal Function? Do you need to adjust dose and frequency? Do you need to measure levels? Vancomycin? Gentamicin? Will you prescribe P or IV antibiotics? Duration of antibiotics? Did you draw cultures before starting antibiotics?
9 Antihypertensive Agents
10 Pain Management
11 Palliative Care Pain Management Dyspnea Management of secretions Private room
12 Reference Harrison s Manual of Medicine
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