in-patient progress note

Template 1

Impression:


Plan:

  • Stroke Etiology:

  • Stroke medical treatment:

    • ASA Started

    • Started on DAPT (dual anti-platelet therapy)

    • Started on Heparin (UFH) | Started on LMWH

  • Stroke work-up:

    • Lipid panel performed. Patient is started on a Statin.

    • ECHO:

    • Holter:

  • Stroke workup - Imaging:

    • Repeat CTA:

    • MRI:

  • Driving:

    • We will fill out a Ministry of Transportation (MoT) Medical Condition Report (July 2018 version) and the patient is aware not to drive and that reporting will be completed.

    • This patient does not require reporting to the MoT (Medical Condition Report, July 2018 version) at this time given absence of motor (physical impairment), cognitive impairment, or visual field impairment.

  • Family/Patient Update: Discussion with the patient/SDM regarding findings and the treatment plan including other options (risks, benefits, alternatives). Discussed risks of bleeding with regards to ASA/Anticoagulation. Discussion occurred using lay language. All questions answered.

Template 2

PATIENT PROFILE:

Patient seen and reviewed in person during bedside Stroke Team rounds.

Overnight issues as applicable, reviewed.
Vital sign value in AM rounds reviewed.
Labs reviewed (recent).
Medications reviewed - daily review.
Imaging reviewed (recent)

Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1000 AM without Orange team colleagues for NVU Level 1 patients:
Meeting with Team lead, SW, OT, PT, SLP, MD Team. Discussed clinical status, discussed disposition plan.

CLINICAL PLAN:

Template 3

Profile:
-

Patient seen and reviewed in person during bedside Stroke Team rounds.
Overnight issues as applicable, reviewed.
Vital sign value in AM rounds reviewed.
Labs reviewed (recent).
Medications reviewed - daily review.
Imaging reviewed (recent)

Discussed in Stroke multidisciplinary rounds, 0930-0945; Then 0945-1000 AM without Orange team colleagues for NVU Level 1 patients:
Meeting with Team lead, SW, OT, PT, SLP, MD Team. Discussed clinical status, discussed disposition plan.

CLINICAL PLAN:
-
-
-
-Medical care: DVTp, Diet, Activity Reviewed, Allied Health Team (PT, OT, Dietician) implementing their assessment-based plan - please see their notes for details.