GynGyn Onc Student Progress Note pneumonia

							                  Gyn/Gyn Onc Student Progress Note                                         Gyn/Gyn Onc Student Progress Note

Date:                                                                     Date:
Time:                                                                     Time:

POD#1 (HD#1) Procedure: s/p____ [TAH/BSO, Staging, D&C, LSC               POD#1 (HD#1) Procedure: s/p____ [TAH/BSO, Staging, D&C, LSC
Salpingectomy, Xlap, etc. for [PMB, pelvic mass, ectopic preg, SBO,       Salpingectomy, Xlap, etc. for [PMB, pelvic mass, ectopic preg, SBO,
etc.]                                                                     etc.]

S: +/- c/o, N/V, SOB, CP, F/C. Tolerating reg/fulls/NPO. Pain well        S: +/- c/o, N/V, SOB, CP, F/C. Tolerating reg/fulls/NPO. Pain well
controlled, ambulating, BM/flatus (if post-op), urinating, any events     controlled, ambulating, BM/flatus (if post-op), urinating, any events
overnight. VB and number of pads if applicable.                           overnight. VB and number of pads if applicable.

O: Tm: (& time)/Tc: BP: current (range) P: R: O2 sat: Ins/Outs:           O: Tm: (& time)/Tc: BP: current (range) P: R: O2 sat: Ins/Outs:
   EX:1500NS/1300uop over 12 hrs, 200NG                                      EX:1500NS/1300uop over 12 hrs, 200NG
   Gen: AAOx3, comfortable                                                   Gen: AAOx3, comfortable
   CV:                                                                       CV:
   Lungs:                                                                    Lungs:
   Abdomen: soft, NT(ApprT)ND, +BS, (if ttp: guarding, rebound)              Abdomen: soft, NT(ApprT)ND, +BS, (if ttp: guarding, rebound)
   Inc: Remove bandage POD1!! c/d/i with: staples, etc                       Inc: Remove bandage POD1!! c/d/i with: staples, etc
        No erythema, exudate, induration, +drain in place                         No erythema, exudate, induration, +drain in place
   GU: vag pack in place (don’t need to do GU exam, just know if vag         GU: vag pack in place (don’t need to do GU exam, just know if vag
        pack present. Resident will remove/instruct.)                             pack present. Resident will remove/instruct.)
   Ext: c/c/e (pitting), Nontender, no cord, SCD’s present                   Ext: c/c/e (pitting), Nontender, no cord, SCD’s present

   Labs: PCV pre-op→ opst-op, blood sugars, any new labs not previously      Labs: PCV pre-op→ opst-op, blood sugars, any new labs not previously
        documented                                                                documented
   Imaging: any new studies not previously documented.                       Imaging: any new studies not previously documented.
   Meds: Abx and day # (ex: Day #2 A/G/CO Include IVF’s and rate)            Meds: Abx and day # (ex: Day #2 A/G/CO Include IVF’s and rate)

A/P: ___yo__F HD#1 for_____ or POD#1 s/p____for____. VB improved,         A/P: ___yo__F HD#1 for_____ or POD#1 s/p____for____. VB improved,
abd pain improved, etc. or Doing well, stable                             abd pain improved, etc. or Doing well, stable
   If not post-op, address active issues: for example                        If not post-op, address active issues: for example
       1. VB - s/p IV estrogen and methergine                                    3. VB - s/p IV estrogen and methergine
       2. Anemia – s/p 2 units. PCV 21->27 HD stable.                            4. Anemia – s/p 2 units. PCV 21->27 HD stable.
   Address surgical issues:                                                  Address surgical issues:
        1. RPOC – d/c foley, plan for voiding trial if need, advance              2. RPOC – d/c foley, plan for voiding trial if need, advance
             diet, HLIV, vag pack/ bandage removed, ambulate,                          diet, HLIV, vag pack/ bandage removed, ambulate,
             change to PO pain meds, wean oxygen if not on at home.                    change to PO pain meds, wean oxygen if not on at home.
   Always address:                                                           Always address:
        1. PPx: SCD/TED, Lovenox, PPI, Abx                                        3. PPx: SCD/TED, Lovenox, PPI, Abx
        2. FEN – Diet, are we advancing or making NPO                             4. FEN – Diet, are we advancing or making NPO
             Fluids – decreasing, increasing                                           Fluids – decreasing, increasing
             UOP – adequate? Foley in? D/C’ing foley?                                  UOP – adequate? Foley in? D/C’ing foley?
   BRIEFLY address other medical problems if no issue                        BRIEFLY address other medical problems if no issue
        1. HTN, Asthma, depression – start home meds if appr.                     2. HTN, Asthma, depression – start home meds if appr.
             Which home meds are they on?                                              Which home meds are they on?


                            SIGN YOUR NOTE!!                                                          SIGN YOUR NOTE!!


Daily Thoughts:                                                           Daily Thoughts:
     Can any IV drugs be made PO?                                              Can any IV drugs be made PO?
     How can I get this pt out of bed today?                                   How can I get this pt out of bed today?
     Can the foley, lines, tube come out?                                      Can the foley, lines, tube come out?
     Does pt have bowel fxn and can diet be advanced?                          Does pt have bowel fxn and can diet be advanced?
     Is the social worker aware of the discharge plan?                         Is the social worker aware of the discharge plan?
                                                                                             Gyn/Gyn Onc Student Presentation Template
             Gyn/Gyn Onc Student Presentation Template
                                                                                Ms. ____________ is a _____ yo female who is now hospital day
Ms. ____________ is a _____ yo female who is now hospital day                   number/post-op day number ___s/p__________ for __________. Her
number/post-op day number ___s/p__________ for __________. Her                  post-operative/hospital course has been complicated by ____________
post-operative/hospital course has been complicated by ____________             (ex. Ileus, pneumonia, inability to void.)
(ex. Ileus, pneumonia, inability to void.)
                                                                                This morning, she is without complaints/complains of _________ (ex. Post-
This morning, she is without complaints/complains of _________ (ex. Post-       op abdominal pain, nausea, etc.) She is still NPO or She is/is not tolerating
op abdominal pain, nausea, etc.) She is still NPO or She is/is not tolerating   a _____ diet. She is/is not ambulating. She does/does not have evidence
a _____ diet. She is/is not ambulating. She does/does not have evidence         of bowel function (i.e. flatus, bowel movement).
of bowel function (i.e. flatus, bowel movement).
                                                                                Over the last 24 hours, her Tmax was _____. She has now been afebrile
Over the last 24 hours, her Tmax was _____. She has now been afebrile           since _____ (If ever febrile). Other vital signs are stable, and she has had
since _____ (If ever febrile). Other vital signs are stable, and she has had    adequate urine output with _____ cc over 24hrs. Her physical exam is
adequate urine output with _____ cc over 24hrs. Her physical exam is            within normal limits/is unchanged. (If post-op, be sure to comment on
within normal limits/is unchanged. (If post-op, be sure to comment on           abdominal exam and incision, keeping in mind that some abdominal
abdominal exam and incision, keeping in mind that some abdominal                tenderness is normal post-op. Also comment on other pertinent findings,
tenderness is normal post-op. Also comment on other pertinent findings,         such as lung exam with pneumonia/pulm, edema, or extremity exam if
such as lung exam with pneumonia/pulm, edema, or extremity exam if              working up for DVT.
working up for DVT.
                                                                                Her hematocrit is ____, from ____ pre-op (Also comment on other
Her hematocrit is ____, from ____ pre-op (Also comment on other                 pertinent labs, such as WBC if febrile or admitted for neutropenia, platelets
pertinent labs, such as WBC if febrile or admitted for neutropenia, platelets   if admitted with thrombocytopenia, creatinine if admitted to evaluate kidney
if admitted with thrombocytopenia, creatinine if admitted to evaluate kidney    status).
status).
                                                                                The plan for her today on POD1 is to d/c Foley (+/- voiding trial), change to
The plan for her today on POD1 is to d/c Foley (+/- voiding trial), change to   p.o. pain meds, HLIV, advance diet, ambulate. (Other things may include
p.o. pain meds, HLIV, advance diet, ambulate. (Other things may include         starting home meds, addition of antibiotics, imaging or other procedures,
starting home meds, addition of antibiotics, imaging or other procedures,       etc.)
etc.)
                                                                                Try to organize presentation plan by system or problem if many issues or
Try to organize presentation plan by system or problem if many issues or        complex course.
complex course.