፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 1 of 2
Date: Time: PID: POD:
Events Last 24 Hours:

Injuries: Pertinent PMH/Social Hx:

CAD HTN MI Afib
DM PVD GERD
Other:
ETOH Smoking Other:
Allergies:

Vitals: HR: BP: / RR: Tm/Tc: O2 Sat:

អ none or
Vent Settings: ABG:
Cardiac Numbers: អ none or CO: CI: SVR:
Outputs: uo: /8 hour NG Tube: /8 hour Chest Tube: Other:
/24 hour /24 hour L /24 hour Leak yes no
R /24 hour Leak yes no

Inputs: IV Fluid: TPN: Tube Feeds: / @ mL/hour Total Input and Output:
@ mL/hour mL/hour Free Water: mL q hour /

Lines/Tubes: Swan (Day ) TLC (Day ) Cordis (Day ) Art. line (Day )
NG Tube Dobhoff PEG PEJ
Physical Exam: Medications:
General Vasopressor Drips: អ None Other Medications:

HEENT
Sedation/Analgesia: អ None

Pupils

Neck
C-collar yes / no Reason? Paralytics: អ None
Chest

Antibiotics: អ None
Abdomen
(day #/total)

Back
Stress Ulcer Prophylaxis:
Famotidine Pantoprazole Sucralfate None
Extremities WB Status OOB yes / no IV / PO
Pulses DVT/PE Prophylaxis: Lovenox Other:
Neuro Subcut. Heparin SCD's
GCS Coumadin IVC Filter None
KEY: CO = cardiac output PID = post injury day Tc = current temperature
GERD = gastroesophageal reflux disease PVD = peripheral vascular disease TLC = triple lumen catheter
IVC = inferior vena cava SCD's = sequential compression devices Tm = maximum temperature
PEJ = percutaneous endoscopic jejunostomy SVR = systemic vascular resistance WB = weight bearing
Rev. 12/03 ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY
 ፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 1 of 2
Date: Time: PID: POD:
Events Last 24 Hours:

Injuries: Pertinent PMH/Social Hx:

CAD HTN MI Afib
DM PVD GERD
Other:
ETOH Smoking Other:
Allergies:

Vitals: HR: BP: / RR: Tm/Tc: O2 Sat:

អ none or
Vent Settings: ABG:
Cardiac Numbers: អ none or CO: CI: SVR:
Outputs: uo: /8 hour NG Tube: /8 hour Chest Tube: Other:
/24 hour /24 hour L /24 hour Leak yes no
R /24 hour Leak yes no

Inputs: IV Fluid: TPN: Tube Feeds: / @ mL/hour Total Input and Output:
@ mL/hour mL/hour Free Water: mL q hour /

Lines/Tubes: Swan (Day ) TLC (Day ) Cordis (Day ) Art. line (Day )
NG Tube Dobhoff PEG PEJ
Physical Exam: Medications:
General Vasopressor Drips: អ None Other Medications:

HEENT
Sedation/Analgesia: អ None

Pupils

Neck
C-collar yes / no Reason? Paralytics: អ None
Chest

Antibiotics: អ None
Abdomen
(day #/total)

Back
Stress Ulcer Prophylaxis:
Famotidine Pantoprazole Sucralfate None
Extremities WB Status OOB yes / no IV / PO
Pulses DVT/PE Prophylaxis: Lovenox Other:
Neuro Subcut. Heparin SCD's
GCS Coumadin IVC Filter None
KEY: CO = cardiac output PID = post injury day Tc = current temperature
GERD = gastroesophageal reflux disease PVD = peripheral vascular disease TLC = triple lumen catheter
IVC = inferior vena cava SCD's = sequential compression devices Tm = maximum temperature
PEJ = percutaneous endoscopic jejunostomy SVR = systemic vascular resistance WB = weight bearing
Rev. 12/03 ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY
 ፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 1 of 2
Date: Time: PID: POD:
Events Last 24 Hours:

Injuries: Pertinent PMH/Social Hx:

CAD HTN MI Afib
DM PVD GERD
Other:
ETOH Smoking Other:
Allergies:

Vitals: HR: BP: / RR: Tm/Tc: O2 Sat:

អ none or
Vent Settings: ABG:
Cardiac Numbers: អ none or CO: CI: SVR:
Outputs: uo: /8 hour NG Tube: /8 hour Chest Tube: Other:
/24 hour /24 hour L /24 hour Leak yes no
R /24 hour Leak yes no

Inputs: IV Fluid: TPN: Tube Feeds: / @ mL/hour Total Input and Output:
@ mL/hour mL/hour Free Water: mL q hour /

Lines/Tubes: Swan (Day ) TLC (Day ) Cordis (Day ) Art. line (Day )
NG Tube Dobhoff PEG PEJ
Physical Exam: Medications:
General Vasopressor Drips: អ None Other Medications:

HEENT
Sedation/Analgesia: អ None

Pupils

Neck
C-collar yes / no Reason? Paralytics: អ None
Chest

Antibiotics: អ None
Abdomen
(day #/total)

Back
Stress Ulcer Prophylaxis:
Famotidine Pantoprazole Sucralfate None
Extremities WB Status OOB yes / no IV / PO
Pulses DVT/PE Prophylaxis: Lovenox Other:
Neuro Subcut. Heparin SCD's
GCS Coumadin IVC Filter None
KEY: CO = cardiac output PID = post injury day Tc = current temperature
GERD = gastroesophageal reflux disease PVD = peripheral vascular disease TLC = triple lumen catheter
IVC = inferior vena cava SCD's = sequential compression devices Tm = maximum temperature
PEJ = percutaneous endoscopic jejunostomy SVR = systemic vascular resistance WB = weight bearing
Rev. 12/03 ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY
 ፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 2 of 2

Date: Time: X-Rays:

Diet: Clears Regular NPO
Labs:

Culture Results:

Assessment and Plan:

Resident Attending
Neuro/Sedation: Neuro/Sedation:

Respiratory: Respiratory:

CV: CV:

GI/Nutrition: GI/Nutrition:

Renal/Fluids: Renal/Fluids:

Infectious Disease: Infectious Disease:

Heme: Heme:

Other: Other:

Resident Signature: Resident Name: Pager:

Trauma Attending Note:
I have seen and evaluated the patient with the medical staff, confirmed their findings as above and noted the above
attending findings as well.
Total Time Spent (not including procedures):

Attending Signature: Attending Name:

ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY
 ፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 2 of 2

Date: Time: X-Rays:

Diet: Clears Regular NPO
Labs:

Culture Results:

Assessment and Plan:

Resident Attending
Neuro/Sedation: Neuro/Sedation:

Respiratory: Respiratory:

CV: CV:

GI/Nutrition: GI/Nutrition:

Renal/Fluids: Renal/Fluids:

Infectious Disease: Infectious Disease:

Heme: Heme:

Other: Other:

Resident Signature: Resident Name: Pager:

Trauma Attending Note:
I have seen and evaluated the patient with the medical staff, confirmed their findings as above and noted the above
attending findings as well.
Total Time Spent (not including procedures):

Attending Signature: Attending Name:

ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY
 ፤ Inpatient

STRONG REGIONAL
TRAUMA/BURN CENTER
CRITICAL CARE PROGRESS NOTE

SMH 1337 MR
Page 2 of 2

Date: Time: X-Rays:

Diet: Clears Regular NPO
Labs:

Culture Results:

Assessment and Plan:

Resident Attending
Neuro/Sedation: Neuro/Sedation:

Respiratory: Respiratory:

CV: CV:

GI/Nutrition: GI/Nutrition:

Renal/Fluids: Renal/Fluids:

Infectious Disease: Infectious Disease:

Heme: Heme:

Other: Other:

Resident Signature: Resident Name: Pager:

Trauma Attending Note:
I have seen and evaluated the patient with the medical staff, confirmed their findings as above and noted the above
attending findings as well.
Total Time Spent (not including procedures):

Attending Signature: Attending Name:

ORIGINAL - CHART COPY CANARY - BILLING COPY PINK - OFFICE COPY