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Internal Medicine Progress Note Template

This document contains a patient progress note from an internal medicine attending physician. It includes sections for history, exam findings, tests reviewed, management options, assessment, current medications, problems, and plan. The note documents the physician confirming and agreeing with the history, exam, assessment and plan of another doctor for their daily evaluation of the patient.

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lindsay_weiss_6
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348 views2 pages

Internal Medicine Progress Note Template

This document contains a patient progress note from an internal medicine attending physician. It includes sections for history, exam findings, tests reviewed, management options, assessment, current medications, problems, and plan. The note documents the physician confirming and agreeing with the history, exam, assessment and plan of another doctor for their daily evaluation of the patient.

Uploaded by

lindsay_weiss_6
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

MCV Hospitals and Physicians VCU Health System Richmond, Virginia 23298 PATIENT PROGRESS NOTES

Internal Medicine Attending Physician Daily Progress Note

Date: ___________ Time: _________

I have interviewed & examined the patient, & confirmed and agree with the history, examination, assessment & plan of Dr. ____________________________. HISTORY:

ROS (

if done, circle abnormal)


___ Muscle - pain, weakness ___ Breast - pain, abscess, mass, discharge ___ Neuro - weakness, paralysis, memory, insomnia ___ Psych - fatigue, insomnia, mood, depression, crying ___ Endocrine - polyuria, polydypsia, cold/heat intolerance ___ Heme petechiae, ecchymosis, easy bruisability ___ Skin rash, tattoos, scars, edema

___ General weight loss, fevers, chills, night sweats ___ Eyes - poor vision, pain ___ ENT - sore throat, pain, runny nose, dysphagia ___ CV - pain, palpitations, hypo/hypertension ___ Resp - dyspnea, cough, tachypnea, wheezing ___ GI - pain, nausea, vomiting, diarrhea, constipation ___ GU - pain, bleeding, incontinent, nocturia, smell

EXAM Area VS/Gen. Eyes ENT/ Neck/ Breast

CV

Lungs GI

GU Musculoskeletal Skin Neuro Psych

Lymphatic

Element ______P, _________BP, ____R, ______T, __General __Conjunctivae, lids, pupils & irises __ Fundoscopic __Ears & nose, external canals & TMs __Nasal mucosa, septum & turbinate __Lips, gums, teeth __Oropharynx, oral mucosa, salivary glands __Hard & soft palates, tongue, tonsils & post. pharynx __Thyroid __Neck __Breasts & axillae __Palpation & auscultation of heart __Carotid art. __Abd aorta __Fem art. __Pedal pulses __Extremities for edema &/or varicosities __Resp effort __Percussion & auscultation of lung __Abdomen - note presence of masses or tenderness __Liver & spleen __Anus, perineum, rectum, sphincter tone, FOBT __Scrotal contents __Penis __Prostate __Gait & station __Digits, nails __Joints, bones, muscles __ROM, Stability __Palpate skin (edema) & SQ tissue __Cranial nerves __ Strength & tone __DTRs __Sensation __Cerebellum __Judgment & insight __Mood & affect __Orientation to time place, person __Recent & remote memory __Lymph nodes in 2 or more areas

Results (

alone = normal, if abnormal write results)

Internal Medicine Attending Physician Daily Progress Note (continued)


TESTS REVIEWED __CBC __Chemistry __Chest x-ray __CT scans __Cultures __Other _______________ MANAGEMENT OPTIONS __Drug changes __Surgery planned __IV fluids __Transfusion __IV antibiotics __Other:

ASSESSMENT:

Current Medications

Problem: 1.

Plan:

2.

3.

4.

5.

6. Disposition/Discharge Planning

___________________________________________________ .

______________ Level of service

MCV Hospitals and Physicians VCU Health System Richmond, Virginia 23298 PATIENT PROGRESS NOTES Internal Medi
Internal Medicine Attending Physician Daily Progress Note (continued) TESTS REVIEWED MANAGEMENT OPTIONS __C

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