Inpatient PhysicianDocumentationSamplesClient Server 5.64 – v.1

Author: Jamie Powell, RN, BSNWritten: 6/29/2011

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 2 of 19 J. Powell

Table of Contents

Current Templates for Review........................................................................................................ 3Admission Note .............................................................................................................................. 3

HPI .............................................................................................................................................. 3Admission Note .............................................................................................................................. 4

PMH............................................................................................................................................ 4PMH Expanded........................................................................................................................... 5PSH ............................................................................................................................................. 7Allergy / Meds ............................................................................................................................ 7Family Hx ................................................................................................................................... 8Social Hx..................................................................................................................................... 9ROS........................................................................................................................................... 10Exam – Collapsed ..................................................................................................................... 12Results....................................................................................................................................... 14Primary Dx................................................................................................................................ 14Second Dx................................................................................................................................. 14Impression / Plan....................................................................................................................... 15

Progress Note ................................................................................................................................ 15Subjective.................................................................................................................................. 15Objective ................................................................................................................................... 15Assessment................................................................................................................................ 16Plan ........................................................................................................................................... 16

Discharge Packet........................................................................................................................... 17Anesthesia PreOp Note ................................................................................................................. 17

Surgical Information ................................................................................................................. 17PMH.......................................................................................................................................... 17Addendum................................................................................................................................. 18Departure................................................................................................................................... 19

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 3 of 19 J. Powell

Purpose: Snapshots of current PDoc Template Build for Review and Discussion

Current Templates for Review

Admission Note

HPI

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 4 of 19 J. Powell

Admission Note

PMH

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 5 of 19 J. Powell

PMH Expanded

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 6 of 19 J. Powell

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 7 of 19 J. Powell

PSH

Allergy / Meds

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 8 of 19 J. Powell

Family Hx

Note: You may want multiples instead in the event there are more than one family member withthe same history, or document as a comment.

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 9 of 19 J. Powell

Social Hx

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 10 of 19 J. Powell

ROS

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 11 of 19 J. Powell

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 12 of 19 J. Powell

Exam – Collapsed

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 13 of 19 J. Powell

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 14 of 19 J. Powell

Results

Primary Dx

Second Dx

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 15 of 19 J. Powell

Impression / Plan

Progress Note

Subjective

Objective

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 16 of 19 J. Powell

Assessment

Plan

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 17 of 19 J. Powell

Discharge Packet

Anesthesia PreOp Note

Surgical Information

PMH

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 18 of 19 J. Powell

Addendum

Inpatient Physician Documentation Samples

All information is provided to be as accurate as possible, but not guaranteed.** User accepts all liability and consequences of any actions taken on the basis of the information provided. **

Printed: 8/23/2012 10:47 AM 19 of 19 J. Powell

Departure