Writing Progress Notes

Daily progress notes should be in the form discussed on work round presentation. A quick example follows:

Subjective	Juan is a seven-year-old with Reactive Airway Disease; day 2 of hospitalization. Improved overnight but continuing in mild respiratory distress. No complaints of fever and decreasing rhinorrhea. Resting fairly comfortably this a.m.
Objective	98.6 PR BP 90/60 HR 90 RR 28 In: 750 IV, 750 PO Out: 500 cc (1.2 cc/kg/hr)
	PE:	HEENT: MMM, slight nasal discharge evident, oropharynx clear without exudate Chest: Mild intercostal retractions, I:E 1:2, diffuse bilateral mild wheezing with good air entry Heart: RRR, nl s1s2 no m/r/g Abd: Soft, NT, ND Ext: Warm and well-perfused
	Labs: Aminophylline level 16.3 (12 hrs of drip @ 1.0 mg/kg/hr)
Assess/Plan	#1 Reactive Airway Disease Improving on current regimen of Proventil nebs q4 hours, aminophylline drip at 1.0 mg/kg/hr and IV solumedrol 1.0 mg/kg q6h. Taking good POs, so will d/c aminophylline drip and switch to po aminophylline 20 mg/kg/day divided q8 and recheck blood level. Still symptomatic, so continue the current regimen of a beta agonist, an anti-inflammatory and a phosphodiesterase inhibitor to cover both the early and late phase of asthma. If respiratory status improves, consider switch to PO steroids. Consider leukotriene inhibitors or cromolyn at home to reduce exacerbations (8 hospitalizations in last 18 months). #2 URI Symptoms resolving. He defervesced yesterday afternoon, now with decreasing rhinorrhea. Fever and rhinorrhea at admission with lymphocytosis on initial CBC suggest a viral URI. Plan is to follow his temperature curve #3 Disposition Will contact PMD regarding long term management of Juan's asthma. Signature CC3