Critical Care Note

 
 
MLPINITIAL
CONSULTATION
CONSULTING SERVICE: Asked by Dr. *** from *** service.
HISTORY:
CHIEF COMPLAINT:***
HISTORY OF PRESENT ILLNESS: (AT LEAST 4 Location, Quality, Severity, Duration, Timing, Context, Modifying Factors, Associated Symptoms OR AT LEAST 3 Status of chronic health problems - REMINDER ONLY:DELETE THIS FROM NOTE)***
REVIEW OF SYSTEMS:
Constitutional -- {CONSTITUTIONAL:21394}
Eyes -- {EYES-ROS (BMT):18956}
ENT -- {ENT (PULMONARY):13058}
Cardiovascular -- {CV (PULMONARY):13060}
Respiratory -- {RESP (BMT):18959}
Gastrointestinal -- {GI (PULMONARY):13061}
Genitourinary -- {GU (PULMONARY):13062}
Musculoskeletal -- {MUSCULO (GI/HEP):18488}
Skin and Breast -- {SKIN (PULMONARY):13056}
Neurological -- {NEURO ROS NEUROLOGICAL:11318}
Psychiatric -- {NEURO ROS PSYCH POS/NEG:11154}
Endocrine -- {NEURO ROS ENDOCRINE:11315}
Hematological -- {NEURO ROS HEME/LYMPH:11320}
Allergic -- {ALLERGY (SBDCTR):15681}
PAST MEDICAL HISTORY:
@MEDICALHX@
@SURGICALHX@
FAMILY HISTORY:***
@FAMHX@
SOCIAL HISTORY:
@SOCH@
ALLERGIES:
@ALLERGY@
MLPNEW
PATIENT: @NAME@
MRN: @MRN@
LENGTH OF STAY: @LOS@
NEUROCRITICAL CARE ICU PROGRESS NOTE
HISTORY: ***
HOSPITAL COURSE:
mm/dd -- ***
mm/dd -- ***
SIGNIFICANT OVERNIGHT EVENTS: *** (If writing a consult or initial admit note, delete this and the above sections; use smart phrase mlpinitial)
COMPREHENSIVE PHYSICAL EXAM:
VITALS:
Tmax -- @TMAXREF(24)@
Pulse -- @FLOWSTATREF(9990099980,8:24)@
SBP -- @SBPMAXREF(24)@
DBP -- @DBPMAXREF(24)@
GENERAL: ***No apparent distress
EYES: ***No ptosis, clear conjunctivae. Pupil exam as in NEURO exam below
PSYCHIATRIC:
Level of Sensorium --
Orientation --
NEUROLOGICAL:
Language Fluency --
CN --
Motor Strength --
RUE LUE
RLE LLE
Motor Tone --
MUSCULOSKELETAL: Motor strength & tone as in NEURO exam above
CARDIOVASCULAR:
Peripheral Pulses -- ***Dorsalis pedis & posterior tibialis pulses 2+ bilaterally
Auscultation -- ***RRR. Normal S1 S2. No murmur
RESPIRATORY:
Effort -- ***Normal
Auscultation -- ***Breath sounds clear and symmetric
ABDOMEN:
Palpation -- ***No tenderness or masses. No organomegaly
Auscultation -- ***... bowel sounds
SKIN:
Inspection -- ***No masses or lesions by inspection
Palpation -- ***No masses or lesions by palpation
DECISION MAKING BY SYSTEM:
NEUROLOGICAL:
Imaging in last 24 hours: ***
ICP: *** EVD: at *** cmH20 ( ml/24hr output)
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
CARDIOVASCULAR SYSTEM:
Blood pressure goals: ***
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
RENAL SYSTEM:
Labs: @RESUFASTREF(na,k,cl,co2,bun,creat,ca,mg,phos)@
Fluid balance: @IOBRIEFREF@
IVF's:
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
RESPIRATORY SYSTEM:
O2 Sats:@FLOWSTATREF(10:24)@
FiO2: @FLOWSTATREF(53100057:24)@
TV: @FLOWSTATREF(330007074356:24)@
Pt rate: @FLOWSTATREF(330007074354:243)@
Set Rate: @FLOWSTATREF(53100056:24)@
PEEP: @FLOWSTATREF(53100058:24)@
PAP: @FLOWSTATREF(330007074351:24)@
Arterial Blood Gas:
@RESUFASTREF(phart,pco2art,po2art,bicarbonate,be,o2sat)@
CXR in last 24 hrs (prelim): ***
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
GASTROINTESTINAL/ENDOCRINE SYSTEMS:
Last BM: PTA
Feeds: TF @ *** (goal *** ml/hr)
Glucose: ***adequate control
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
INFECTIOUS DISEASE:
Cultures: MRSA – pend VRE – pend
Blood ( / ) – pend
Urine ( / ) – pend
Sputum ( / ) – pend
Antibiotics:
Assessment and Plan:
Problem 1
--detail
--detail
Problem 2
--detail
--detail
HEMATOLOGICAL SYSTEM:
@RESUFASTREF(wbc,rbc,hgb,hct,plt,mcv)@
Assessment and Plan:
Problem 1
--detail
-detail
Problem 2
--detail
--detail
SKIN/LINES/DRAINS/DEVICES:
--Need for all catheters and drains reviewed
--All thought to be necessary at this time.
PROPHYLAXIS/MISCELLANEOUS:
Head of bed at 30 degrees to prevent aspiration
DVT Prophylaxis: SCD's on patient
Restraints:
Code: FULL
I reviewed the lab results as noted above and other pertinent labs in the EMR.
I personally reviewed the EKG/telemetry rhythm and these radiological studies: ***.
Case was discussed with attending physician, Dr. ***.
***If billing critical care use smart phrase mlpcc. Please delete this sentence
@SIGN@
Neurocritical Care Service
MLPBRIEF
Brief ICU Post-op Note
I reviewed the patient's medical record and examined the patient.
Procedure performed: ***
Significant intra/post-operative events: *** None
Post-op Neurological Exam: ***
Significant abnormal post-op lab values or radiological studies: ***
Plan: ***
Discussed with ***
@SIGN@
This patient is critically ill due to an acute impairment of the following system(s):
This is the result of the following conditions that have a high probability of causing imminent life threatening deterioration that requires my personal management:
I provided *** minutes of critical care to this patient. This includes a review of recent events and medical history, detailed clinical examination at the bedside, interpretation of multiple physiological parameters, laboratory data and imaging studies. I performed high complexity decision making to assess, manipulate, and support vital functions as well as discussed the patient's care with members of the multidisciplinary ICU team and other medical providers. Additionally, I personally performed the following actions at the patient’s bedside:
This time DOES NOT include time spent in performing any separately billed procedures or time spent by providers of other specialties performing critical care services.