Abbot;

This IS a STRANGE request indeed. You know this stuff...we did it all through
medical school. You should be better because you did it in PGI and as a
consultant in the Philippines.

Don't panic, you know this.

Advise...summarize the pt's HPI and course in the ER/Ward. Don't write it day by
day like we did in medical school.

For the notes just remember the stuff the USMLE was asking for during the Step 2
CS (formerly known as the CSA)

1. Admitting orders = ADC VAAN DISML

Admit
Dx
Cond

VS
Allergies
Activity
Nurses

Diet
IVF
Sedation/pain meds
Meds
Labs

2. Admitting H/P = CPC PAM HUG FOSS
Code Status
PCP
CC

Present illness (HPI)
Allergies
Meds

History (PMH and PSH - include urologic and GI hx)
FH
OBGyne / Birth Hx
SH (including sexual hx)

2. Progress Note = Soap
Subjective
Objective
Assessment
Plan

3. D/C note
Date of admission and Dx
Date of d/c and Dx
Service
Referring MD
Consults
Procedures
H/P (complete...including admitting meds)
course in the ER
course in the Ward
Disposition
Instructions
D/C meds
F/up



--- In SamahangMedisinaFEUNRMF@yahoogroups.com, "George Bush" <bertito05md@...>
wrote:
>
> Hello Everyone,
>
> I hope this may sound so strange but I would like to ask anyone in this forum
if you could send me as an attached document of the above mentioned notes. I
need them so that I could brushing up my note making skills. You response is
highly appreciated. Thanks.
>