DEPARTMENT OF SURGERY
ORTHOPEDIC SURGERY
SUBSEQUENT INPATIENT VISIT NOTE
E/M
Level
Patient Identification
Q.D. – write daily/ u – write unit / Q.O.D. – write every other day / I.U. – write International Units
MS or MSO4 – write Morphine Sulfate / MgSo4 – write Magnesium Sulfate
Avoid trailing zero (e.g. 5.0 mg) / Use a leading zero (e.g. 0.5 mg)
Date:
Primary Physician:
Unable to obtain (state reason)
INTERVAL HISTORY:
Additional History per family/caregiver (name)
(Location-Timing-Duration-Context-Modifying Factors-Severity
Severity-Assoc. SX)
(HPI) SUBJECTIVE
DVT Prophylaxis:
Lovenox
TED Hose
Arixta
PCD
Reason for not administering VTE prophylaxis:
prophylaxis
Active Bleeding
Patient Refusal
High Risk for Post-op Bleeding
Thrombocytopenia
Review of Systems:: (write pertinent positives and negatives of affected systems)
Unable to obtain (state reason):
No Complaints
No Acute Events
Pain Controlled
Nausea/Vomiting
EXAM: Check box if normal, document specific abnormal or relevant negative exam findings of the affected systems.
Diet:
Regular
ADA
Other:
AHA
Renal
Allergies:
NKA
Vital Signs:
AF VSS
Pulse
BP
Resp
Pulse Ox
WT
(kg) BMI
T
Intake & Output
O2 LPM
General Appearance:
Eyes:
WNL
PERLA
Neuro:
A/O, Grossly intact
Other:
Other:
Nose:
WNL
NCO2
GI(Abd):
+BS, soft, NT
Other:
Other:
Throat:
WNL
Tongue midline
Musculoskeletal:
WNL
Up w/ minimal assist
Other:
Needs assist, see PT Notes
Cardio:
WNL/RRR
Murmur
Cardio Brruits
GU:
Voiding
Incontinence
Other:
Foley day #
Reason for extended Foley use:
Resp:
Clear to Auscultation – Bilateral
Shortness of Breath
Wheezes
Rhonchi
Rales
Wound:
Site healing well, no sign of infection.
Dressing changed, Date:
Dressing changed, Date:
Cultures/Pathology:
Blood Glucose:
HgA 1-C:
Medications/New/Changes:
Unchanged from:
DATA REVIEWED/Requested/Discussed with Dr.
Continue Antibiotics >24 hours after anesthesia
(Indicate Infection Location & Diagnosis)
Possible Bone/Tissue Infection
Other:
Refer to medication reconciliation form.
GFR:
Mag:
PT/PTT:
INR:
PO4:
Other:
Albumin:
RADIOLOGY
1.
2.
Viewed and interpreted by me.
Viewed and interpreted by me.
MR Form S8092-100
100
0
07/11
Page 1 of 2
DEPARTMENT OF SURGERY
ORTHOPEDIC SURGERY
SUBSEQUENT INPATIENT VISIT NOTE
E/M Level
Patient Identification
Medical Decision Making
Assessment (e.g. Symptoms, Diagnosis, Possible Diagnosis)
POD#
Labs Reviewed
Surgical Dx:
Location:
Left Upper
Extremity
Neurovascularly
intact
Compartment
Area Soft
Wound/Incision
clean, dry, intact,
healing well
Dressing/Splint
clean, dry, and intact
Secondary Dx:
Plan: (e.g. Treatment Options, Additional Testing, Therapeutic Interventions)
Left Lower
Extremity
Neurovascularly
intact
Compartment
Area Soft
Wound/Incision
clean, dry, intact,
healing well
Dressing/Splint
clean, dry, and intact
PT
OT
Weight Bear as tolerated
Non Weight Bear
Partial Weight Bear
Toe Touch Weight Bear
Progressive Range of Motion
Reverse Shoulder
Pendulum
Discharge Planning:
SNF
Home
Home with PT
Right Upper
Extremity
Neurovascularly
intact
Compartment
Area Soft
Wound/Incision
clean, dry, intact,
healing well
Dressing/Splint
clean, dry, and intact
Joint Camp
Hip Program
Shoulder Program
Overhead Pulley
Overhead Supine
Rehab
Resident
Signature:
MD/DO/NP/PA
Pager
Time
Date
Signature:
MD/DO/NP/PA
Pager
Time
Date
I examined and evaluated the patient and agree with the
I examined and evaluated the patient and agree with the
Attending visit, no resident involvement.
Dictated Job #:
Critical Care Time =
Teaching Physician Documentation
resident’s and/or
PA/s findings and plan as documented.
resident’s and/or
PA/s findings and plan as documented, except:
minutes.
Attending
Signature:
PVID
Right Lower
Extremity
Neurovascularly
intact
Compartment
Area Soft
Wound/Incision
clean, dry, intact,
healing well
Dressing/Splint
clean, dry, and intact
MD/DO
Pager
Time
Date
00133
00280
00758
00822
00887
00892
01065
01106
30153
30176
30425
30432
30819
30873
30956
31009
31091
31106
31118
31164
31294
72187
72224
72687
72689
72755
72833
72857
72900
72984
MR Form S8092-100
07/11
Page 2 of 2