I received a wonderful tweet based on my nouns need adjectives post.
I’m prepping materials for incoming interns inspired in part by this. Focus is on notes for our inpatient service. Got anything to add?
The idea is to list common chronic problems and specify information that an admission note should include. Here are my thoughts including his suggestions and my modificationsCOPD – PFTs if done, current meds, home oxygen?, possibly Gold Stage Heart failure – systolic function, define type of heart failure, any valvular disease, current meds, if EF < 35% does patient have AICD, EKG – does the patient qualify for biventricular pacing CKD – Stage, if 3B or 4 are there any metabolic complications yet, etiology, urine protein/creatinine ratio Diabetes – type, duration, current meds, A1c A fib – CHADS-VASC, current anticoagulation or contraindication, AKI – previous creatinine, urine output, likely cause (did we exclude obstruction and volume contraction and medications) CAD – previous documented episodes (previous MIs, stents, CABG), current meds, risk factor Chronic liver disease – etiology if known or do we need to evaluate, MELD score, current meds related to liver disease
I hope this helps.
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