Inaptient note template 001

Dr.Faust

本篇内来源和病史采集那篇类似, 因而就不多废话了. 唯一的问题是笔者上一轮在美国的临床实习inpatient的部分满打满算只有仅仅不到一个半月, 可能需要改正和优化的地方更多一些. 大伙如果有任何疑问和建议, 欢迎在留言区进行友好讨论


另外也希望已经match的前辈们对本篇内容进行指导


  

Name	DOB	Contacts	Handoff ??
	Current status	Most recent labs
Allergies			PMH
Common allergens    Specific allergens    Medications			Last relevant specialist visit    Labs & Imaging    (reason to some specific tests,  i.e. autoimmune workup, hormone, CT&MRIs)    Falls or LOC
	Previous Status	Previous labs
			PSH
			Major surgeries    Inpatient admission & ER  visit    Fractures
Social history    Sexual    Cigarettes & Alcohol    Weeds (currently legal in many  states, but have to mark down if Pt confirms daily use)    Recreational drug use	Current Rx	Vitals	FMH    Parents & Grandparents    Siblings    Offsprings
	Adherence & Response    Recent change in Rx    Ordered by who
	Previous Rx
	Adherence & Response    Recent change in Rx    Ordered by who
	PE	ROS
	Assessments	Orders
	Others