MR Form S8092-107

This form is for use with hospital patients only.

THORACIC & CARDIOVASCULAR CRITICAL CAREPROGRESS NOTE

DO NOT USE THE FOLLOWING ABBREVIATIONSQ.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U.

MS or MSO4 – write Morphine Sulfate / MgSoAvoid trailing zero (e.g. 5.0 mg) / Use

Operation(s):

INTERVAL HISTORY: NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI

Events in past 24 hrs:

General Appearance:

Neuro: Brief assessment of mental status:Exam:

Cardiac: Heart rate: Rhythm: Sinus

Pacing:

Pap: / PCWP:ECG viewed & interpreted by me.

Cardiac/Vascular Exam:

Cardiac Mechanical Support:(VADS/IABP)Pulmonary: Nasal cannula: Mask:

Mechanical ventilation NIPPV: BIPAP:Mode: CMV SIMV PCV APRV Other:

Settings: Set/Spont. rate: / Tidal volume:Chest Tubes Mediastinals:

Chest x-ray viewed & interpreted by me.

Exam:

Pulmonary-Mechanical Support(ECMO):Renal: I/O (24/8) hrs: / CRRT

Exam:

GI/Nutrition: NG tube 24hr drainage NPORate: Goal:

Parenteral: PPN TPN Bowel movement:

Exam:

Infectious Disease:Cultures:

Heme/Lymph:

Endocrine:

Skin Exam:

HEENT:

Musculoskeletal:

This form is for use with hospital patients only.E/M

LevelTHORACIC & CARDIOVASCULAR CRITICAL CAREPROGRESS NOTE

DO NOT USE THE FOLLOWING ABBREVIATIONSwrite every other day / I.U. – write International Units

write Morphine Sulfate / MgSo4 – write Magnesium Sulfatea leading zero (e.g. 0.5 mg)

NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI – Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)

A. fib A. flutter Junctional Other:

Systemic BP: / CVP:

Co/Cl : / SVR:

Mask: Respiratory rate: Secretions:

/ CPAP:

Tidal volume: PEEP PS  FIO2

Pleural Tubes:

HD Net fluid removal:

NPO Enteral NGT SBFT Type:

Bowel movement: Bowel sounds: present / absent

Tmax: Tubes & lines (lineday/siteday)

Page 1 of 2

Patient Identification

Postoperative day:

Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)

Drips & Meds

Fentanyl

Other:

Epinephrine

MilrinoneDobutamineDopamine

Vasopressin

NorepinephrineAmiodarone

MetoprololStatin

ACE IAspirin

AlbuterolOther:

Lasix

Other:

LansoprazoleRanitidine

Bowel sounds: present / absent Pantoprazole

Esomeprazole

lines (lineday/siteday) Antibiotics (day#/Total)

Warfarin

Heparin

Glytec

ICU Insulin Protocol

Insulin Sliding Protocol

MR Form S8092-107 Page 2 of 2

This form is for use with hospital patients only.E/M

LevelPatient IdentificationTHORACIC & CARDIOVASCULAR CRITICAL CARE

PROGRESS NOTEDO NOT USE THE FOLLOWING ABBREVIATIONS

Q.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U. – write International UnitsMS 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) Pg 2 of 2

Assessment, Plan & Treatments (please document diagnosis with treatments): LabsNeuro/Psych Phosphorus

MgLactate

CV

CaBilirubin

Alk. PhosphateAST (SGOT)ALT (SGPT)

Pulm Protein, Tot.Albumin

RenalProtimeINRAPTTOther:

GI/Nutrition

ABG:

/ / / /

SVO2:Infectious Disease

Endocrine

Critical CareVAP precautions Y N

Sedation vacation Y NGI prophylaxis Y N

Heme DVT prophylaxis Y NRestraint orders Y N

Nutritional needs addressed Y NFoley addressed Y N

Line removal addressed Y NFamily updated Y N

Signature: MD Pager Date Time

Teaching Physician DocumentationCritical Care Time: My direct critical care time was Minutes. The time documented above was spent providing direct care to this critically ill patient does not include anytime for Procedures. Furthermore, in calculating this total time I have been careful to only include the minimum time during which I personally was providing the critical care serviceslisted to this patient while I was on the unit or floor.

I examined and evaluated the patient and agree with the resident’s/non-physician provider’s findings and plan as documented, except:

Dictated Job #: 99231 99232 99233 99291 99292 X