The sample notes provide most of the questions to ask while collecting patient history, the common physical findings, and the typical assessment and plan. Having the basics pre-written in front of you may help you discover some unusual and challenging findings in atypical clinical situations.
If you want to print a note, just select the text with the mouse, and choose "print selection" from the print menu.
Cardiology
Admission Note for Shortness of Breath (SOB), CHF
Admission Note for Chest Pain
Admission Note for Syncope
Admission Note for Chest Pain, ICU
Pulmonology and Critical Care
Admission Note for SOB, Asthma
Admission Note for SOB, Pneumonia
Admission Note for Ventilated Patient, ICU
Admission Note for Alcohol or Drug Overdose
Gastroenterology (GI)
Admission Note for N/V/D
Admission Note for GI Bleed
Admission Note for Abdominal Pain
Nephrology
Admission Note for ESRD, HD, AVF
Endocrinology
Admission Note for DKA, ICU
Hematology/Oncology
Admission Note for Sickle Cell Crisis
Rheumatology
Admission Note for Back Pain
Infectious Diseases (ID)
Admission Note for Leg Pain
Admission Note for Infection
Admission Note for Septic Shock, ICU
Admission Note for Pelvic Pain, PID, GU Sx
Neurology
Admission Note for Dizziness
Admission Note for Seizures
Admission Note for Change in MS
References
Audio/Video
SOAP Note 101 Series. The Texas Tech Medcast: A podcast series designed for first-year medical students who are learning how to write an effective patient note for a medical record.
Further Reading
Admission Note - Universal Note
Progress Note - SOAP Format
Procedure Note
Happy's Hospitalist Order Sets, 08/2008.
EMR (Epic) primer: Our Most Expensive Typing Pool. Dr. Wes, 09/2008.
Collecting History: Pulling Teeth. FatDoctor, 01/2008.
Published: 01/06/2004
Updated: 03/30/2010
Procedure Guides
Central line placement. See also Central line placement with ultrasound guidance Thoracentesis (pleural tap)
Paracentesis (ascites tap)
Arthrocentesis (joint tap)
Arterial line placement is illustrated in The Internet Journal of Health.
Lumbar puncture in eMedicine
More links
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