30 likes | 39 Views
<a href="https://www.mytemplate.org/hourly-schedule-templates/">Doctor Progress Note Template</a><br><br><br>Print this blank, lined paper template for your patient charts. Includes room for date and progress notes for the nurse or doctor to document an office visit.
E N D
NF SNF DATE: RESIDENT: ROOM: DOB: PROGRESS NOTE Chief Complaint: Interim History: Allergies: Medications: Nutrition: Weight: Same_____ Decreased_____ Increased_____ Food intake: Mobility: Ambulates unassisted Uses device Wheelchair Bedbound Review of Systems: HEENT: Cardiac: GI: Musculoskeletal: Neuro: Physical Exam: VS: BP: P: R: Temp: Wt: HEENT: Heart: Abdomen: Extremities: Neuro: Nutritional status Mobility: Skin: Labs/Diagnostics: Labs: X-rays: Colnsultations: Assessment: Plan: Medical orders – care plan reviewed Medications reviewed Verbal orders reviewed Treatment plan discussed with patient Family conference Advance Directives No change New Pulmonary: GU: Skin: Psychosocial: Lungs: Mental status/affect: J/Forms/ Progress Note
DOCTOR’S PROGRESS NOTES Last Name First Name Attending Physician Room No. Patient No. Date Hour J/Forms/ Progress Note