Continue to work on a patient

Events: what has happened since we last saw each other/over night/over the weekend?

Subjective:

  • Chief compliant(s)
  • what is the current state of the patient?

Objective:

  • Vitals + weight
  • Exam
  • Labs
  • Imaging
  • Meds
  • comments / notes of other clinicians
  • other data

Evaluate: past interventions

Assessment/Hypothesis:

  • one liner
  • why have things happen the way they did?
  • how do things fit into the broad scheme?
  • Differential Diagnosis

Plan:

  • what is the concrete next step
  • what are other important steps
  • Labs, diet, referral, patient education,
  • todos

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