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Inpatient Visit Note Template

This document provides a template for subsequent inpatient visit notes at UPHS Department of Medicine. The template includes sections for interval history, exam, and medical decision making. The interval history section includes spaces for HPI, medications, ROS, and ability to obtain history. The multi-system exam section lists exam elements under organ systems. The medical decision making section includes spaces for data reviewed, assessment/plan, and resident signature. The attending supplement requires a minimum of one element from history, exam or decision making. It also includes spaces for counseling/coordination of care details and DNR status. Total attending time is documented along with billing codes.

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Janu easwar
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158 views4 pages

Inpatient Visit Note Template

This document provides a template for subsequent inpatient visit notes at UPHS Department of Medicine. The template includes sections for interval history, exam, and medical decision making. The interval history section includes spaces for HPI, medications, ROS, and ability to obtain history. The multi-system exam section lists exam elements under organ systems. The medical decision making section includes spaces for data reviewed, assessment/plan, and resident signature. The attending supplement requires a minimum of one element from history, exam or decision making. It also includes spaces for counseling/coordination of care details and DNR status. Total attending time is documented along with billing codes.

Uploaded by

Janu easwar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
  • Multi-System Exam: Documents the results of the comprehensive physical examination conducted on the patient.
  • Interval History: Collects and reviews the patient's medical history during the current visit.
  • Documentation and Signatures: Includes spaces for signatures and additional notes from attending physicians.
  • Medical Decision Making: Describes the data review, assessments, and plans for continued care.

SAMPLE DOCUMENTATION

TEMPLATES
UPHS – Department of Medicine
Subsequent Inpatient Visit Note

[Link]
UPHS – Department of Medicine
Subsequent Inpatient Visit Note
(Requires 2 of 3 components: history, exam, or medical decision making)

Date: _____________ Time: ___________ Patient Name:


(1) INTERVAL HISTORY: HPI: Level 3 = ≥ 4; Level 1 - 2 = ≤ 3 MEDICATIONS:
ROS: Level 3 = 2 - 9; Level 2 = 1; Level 1 = 0 ■ unchanged from ______________________
location/quality/duration/timing/severity/context/mod factors/assoc s/s
■ unable to obtain (indicate reason)
■ unchanged from ______________

(2) MULTI-SYSTEM EXAM: (any 12 = Level 3; any 6 = Level 2; ≤any 5 = Level 1) Elaborate Abnormal Findings

Constitutional: Lymphatic: no adenopathy (indicate at least two, if applicable)


■ (Document 3) T: ____ P: ____ BP: ____ RR: ____ WT: ____ ■ cervical ■ axillary ■ inguinal ■ supraclavicular
■ See Vital Sign Flow Sheet
■ APPEARANCE: ____________________________________ Musculoskeletal: ■ nl gait
■ no clubbing, cyanosis
Eyes: ■ no scleral icterus ■ nl muscle strength and tone
■ PERRLA
Skin: ■ no rash or ulcers
Ears/Nose/Mouth/Throat: ■ nl teeth, lips, gums
■ no nodules
■ clear oropharynx

Neck: ■ nl appearance and movements; nl JVP Neuro: ■ non-focal


■ trachea midline ■ nl sensation
■ no thyroid enlargement, masses
Psych: ■ alert, oriented to person, place, time
Respiratory: ■ symmetrical chest expansion and respiratory effort ■ nl affect
■ clear to auscultation and palpation
Other:
Cardiovascular: ■ nl sounds; no murmurs, gallops, rubs
■ no edema

Abdominal: ■ no tenderness; nl sounds


■ no hepatosplenomegaly
■ no hernias present

*136560*
*136560* Page 1 of 2 136560 AEL 5/2005
Patient Name_________________________________________________________________ MRN#______________________________________
(3) MEDICAL DECISION MAKING:
Data Review: (Laboratory/Radiology/Additional Records Reviewed) ■ See Lab Report: Data _______________________
■ See Radiology Report: Data _______________
(Attending reviewed above data ________________)

Assessment/Plan: (Possible Diagnoses/Treatment Options/Additional Testing/Therapeutic Interventions)

Resident/Fellow Signature: ________________________________________________ Date: _____________ Pager: _____________


ATTENDING SUPPLEMENT: (Minimum 1 element from 2 components: history, exam, or medical decision making)
I saw and evaluated the patient, and I agree with note by Dr. __________________________________________.

Counseling and/or Coordination of Care (time_______)


(>50% of Total Floor Time; Spent Face-to-Face with Patient/Family)

Discussion Points:

DNR Status:

Attending Signature/Print: _________________________________________________________ Date: _______________ Time: _______________

Total Attending Floor Time (min): _____________


Subsequent: ■ 99231 (15 min) ■ 99232 (25 min) ■ 99233 (35 min) ■ Prolonged Care: Time ________ (Face-to-Face with Patient Only)
■ Discharge Day: Time __________ ■ Critical Care: Total Cumulative Time __________
■ -25 (Separately identifiable E/M service on procedure day)

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