On Service Note or pick-up note

On Service Note or pick-up note

Written by a member of the team taking over the care of a Pt. who has been on the service for some time.

• • Date of Admission:

  • Admitting Dx:

  • Procedures (with results) to Date:

  • Hospital Course to Date: briefly summarized:

  • Brief Physical Examination:

  • Pertinent Lab. Data:

  • Problem List:

  • Assessment:

  • Plan:

Pt is a 52-yo AAM c h/o ... admitted on ... for c/o. Admitting Dx ... Hosp. course to date included (proc. tx.)

SOAP