progress note
suggestions

Template 1

Impression:


Plan:

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.

Template 4

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)

Exam:

-

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.

Patient Update

All discussions occurred using clear language and plain terms, opportunity was provided for the patient to ask questions, and their questions were answered, they were satisfied with the answers provided.

SDM Update

All discussions occurred using clear language and plain terms, opportunity was provided for the SDM to ask questions, and their questions were answered, they were satisfied with the answers provided.