Daily Progress Note
3 chronic/stable conditions:1)htn-stable 2)chol -stable 3)anemia-stable
All 12 Review of Systems negative and no modifying or exacerbating factors except
as noted above. vs also revd in med record and in emr/EHR
General:NAD and normal cephalic atraumatic
Eyes:anicteric,moist conjunctivae;no lid-lag;
HEENT:Atraumatic;oropharynx clear and no ulcerations;normal palate.
Neck:Trachea midline;neck supple,no thyromegaly/LAD
Cardiac: RRR, (-)murmurs,(-)rubs or (-)gallops
Abdomen:Soft, non-tender;no masses or splenomegaly
Extremities:No peripheral cyanosis or lymphadenopathy
Skin:Normal turgor and texture;no rash ulcers;Neuro:Nonfocal,No Babinski
( X ) Independently Revd Consult notes/Meds and Labs today in EHR:
2) HTN- Monitor BP closely,relatively stable
3) Hypercholesterolemia: Med mgmt,stable for now
4) Anemia: check CBC, stable for now
( ) Pt critically ILL:high probability of imminent or life threatening deterioration in the patient's
condition and threat to bodily function; I provided 30 minutes of critical care outside of separately billable procedures and more than half this time was spent in counseling and management of cad /chf/ tachycardia.
t/c order (x ) CBC ( x) BMP (x ) EKG ( x) CXR in am ( ) will try to get old records ( X ) d/w RN/PMD/Family
(x ) Past medical/surgical/social/family history reviewed in HP section of chart done during admission.
( X ) Meds/labs/vital signs(bp hr and RR) reviewed in chart/EHR along with other consultant notes and their recommendations for today when pt was seen. More specific recommendations written in chart.