Basic Information: Patient is a __ year old patient with history

of __(most important chronic medical conditions) who presented to

__ (ED, our service etc) complaining of _. We were consulted for
_. Patient is hospital day _, Post-OP day __ status post ___
(procedure).
SUBJECTIVE: Saw patient this morning ____ (sitting in bed, laying
in bed, on vent etc etc). Patient reports (new complaints or no new
complaints overnight). Nursing reports (events or just no events
overnight). Patient denies/complains of (relevant symptoms like
abdominal pain, DiB, SoB, chest pain...think what is related and
show that you checked here). Patient is eager to go home/patient
remains unresponsive/(patient outlook currently).
OBJECTIVE (all values should cover past 24 hours): VITALS in
ranges for example: HR 80s-100s BP 120s-140s over 60s-80s Tmax
at what time, Tmin at what time, Tcurrent Respiratory rate 12-16
with sats 95%-100% on 2LPM NC (etc)
Input (total then how much via IV (and what fluid at what rate),
how much via oral, how much via tubes, etc etc) and output (total
then break it down and how obtained (like if there is a foley or
condom cath) and then fluid balance for past 24 hours
Current medications, INCLUDING what day of what antibiotics the
patient is on. Further, make sure you know what doses of pain
medications the patient is receiving and how much the patient
received in the past 24 hours. Make sure to check the PCA flow
sheets in the patient's chart if applicable
CBC obtained at (time) showed (read numbers as follows: WBC->Hgb-->HCT-->Platelets)
Lytes at (time) showed (read lyte skeleton as sodium-->K-->Cl->CO2-->BUN-->Cr-->Glucose
Other labs and when they were obtained
Surgically related values (like how much a chest tube drained)
Urinalysis results
Imaging results
Culture results

Any further test results reported in the past 24 hours or important

for managment for this admission (like a positive culture)
Last dressing change, last IV change (also inspect the site)
ROS as obtained that morning from the patient
Physical examination IMPORTANT: ALWAYS INSPECT THE SURGICAL
SITE AND REPORT STATUS OF ERYTHEMA, TENDERNESS, LEAKAGE,
SUTURE STATUS, DRESSING STATUS. This should be limited to
relevant findings to your procedure or diagnoses. Surgeons like
focus. ALWAYS GET: Respiratory, Cardiovascular, Abdominal
examinations no matter what. Dont forget to expose, auscultate,
percuss, and palpitate
ASSESSMENT:
This is a (age) (gender) patient with hx of (main history) status
post (Procedure) for (reason for procedure) (and then any
complications or new developments should be worked into the end
of your assesment opening statement). Patient appears to be
recovering post op with (relevant findings) indicating such OR
Patient is having difficulty post op with (relevant findings).
My differential is: Go for it. You gotta learn how to make a good
differential and the only way to do that is to do it over and over
again. Make a problem list and work your way down it with
differentials or definitive diagnoses ready. Be prepared to defend
your differential from pimping attendings or residents.
PLAN Usually youll have to review a resident's note, but try to come
up with your own plan first to compare. Go problem by problem and
provide solutions. Always consider your prophylaxis measures such
as subQ heparin, SCDs, GI PPx, pulmonary toliet, etc. Point out falls
risk if present. State ambulation, diet, and fluid recs.
So yeah...this might help you a bit or it might not, but hey, youll do
great either way. Surgery can be rough but it also is one of the
more interesting rotations. Enjoy yourself and hey, you never know,
your resident might just let you perform a surgery with him/her
over your shoulder (I got to I/D an abscess with just my resident
hovering over my shoulder...it may be small, but it felt fucking
amazing when you realize you just performed surgery).

---

On IM right now actually!

Basic information
Pt is a (age) (sex) with history of (Main PMHx) (s/p procedures),
hospital day (, POD procedure, s/p days in MICU/NeuroICU/ICU/etc)
who originally presented to our (floor, ED, consult service, etc) c/o
(CC).
(NOW if this patient is new to your service, youll need to sum up
the hospital course. Hit the main points since admission, including
main treatment plans, diagnoses, rapid response/code activations,
MICU admits, surgical procedures, and findings from those times.
Try to make it a story format so that you can read it off from your
note to completely describe in a succinct and complete manner
what happened since the patient arrived at your hospital for this
admission. Remember to consider recent previous admissions for
the same complaint and any MAJOR issues or MAJOR results from
those admissions).
SUBJECTIVE
Always start this section with any major events overnight. If rapid
response was called, lead off with that and explain what happened
and where the patient ended up (MICU etc). OTHERWISE...
Patient was seen (sitting,resting,etc) this morning. Patient denies
any new complaints/is complaining of (new complaints with short,
focused HPIs done). Nursing also reported (events
overnight)/denies events overnight. Patient seems excited for
discharge/upset at progressing illness/etc (like describe patient
outlook here...not necessary but helps put the patient in perspective
to the attending/resident).
ROS positive for blank or otherwise negative except for HPI.
OBJECTIVE
Vitals in ranges (HR, BP, Tmax (if fever present, also note Tmin.
Also note Tmin if patient had severely low temps overnight <36),
Tcurrent, Respirations, Saturations on (Room Air/O2 therapy
amount and method of delivery)).
I/O are nice but usually are not kept as close a watch on as surgery
or nephro. If they are there, check em.

Past 24 hour labs as in surgery, noting trends with abnormal

numbers (so if Hgb is low, point out what baseline is and where it is
trending from)
Radiographs and other imaging
Microbiology results
CONSULT RESULTS INCLUDING RECS!!!
Amount of pain medication overnight and IV fluid rate and type, and
all current medications and prophylactic measures.
PHYSICAL EXAMINATION
If new patient, do a rather full physical (and history but you knew
that) If progress, do a focused examination along with Respiratory,
cardio, and abdominal checks. CHECK EVERY TUBE AND IV AND
LINE FOR ERYTHEMA, TENDERNESS, EDEMA, ETC. Note what day
each was inserted and have nursing change IV's about every 3 days
(go with your hospital's protocol).
ASSESSMENT Repeat your basic info heading line from above
THEN...
Diagnose step by step. Start with the primary problem and work
your way down, including differentials as needed.
So, if c/o cough... "Cough has been determined to be due
community acquire pneumonia due to cultures showing blank along
with CXR which showed blank" The idea is you wanna present your
assessment, then back it up with evidence. If you have multiple
possiblities, point them out along with what supports and what
knocks down each one. Move through the problem list and cover all
abnormalities and chronic conditions so as to allow for a better idea
of the patient's problems and to help guide an overall treatment
plan.
PLAN
For each of the above problems/diagnoses, list what youre gonna
do. What test you wanna order, what you are waiting on test
wise/consult wise. ALWAYS INCLUDE PROPHYLAXIS PLANS.
Incentive spirometry is not as important here if the patient is able
to get out of bed, but gods help ye if those sequential compression
devices are not mentioned (squeezy boots).

They are similar but what your Surgeon wants is a focused note
that highlights all the parameters that matter to surgery. Ive had a
surgeon say "fuck the respirations, she's breathing and that's all I
care about". On the flip side, on IM, YOU ARE THE PRIMARY TEAM.
Your team needs to be on top of ALL of the problems, even if you
are just noting that pharm is dosing vanco on your patient. The
notes are similar, but the focus shifts. Surgeons want short and
sweet and pretty much only care if something is out of normal
values. IM wants to know which grandmother had diabetes. Just
remember to think of IM as the MAIN team and you need to
HANDLE EVERYTHING.