Template for Notes and Presentations

Clinical Rotations for Students

Although the official medical record is now entirely electronic, students may choose to write admission and follow-up notes on lined progress note paper. Whether notes are done electronically or on paper, it is important that the information is recorded and verbally presented in a logical, coherent manner and that a succinct assessment and plan is provided. Our suggested format for both admit and progress notes is presented on this page.

2/9/08 08:15

MS Admission Note

ID: 12 hour old term newborn

HPI: Baby Boy Brown was born at 39+3 weeks by NSVD to a 27yo G3P1011 mom with prenatal labs O+, Ab screen -, HBsAg-, VDRL non-reactive, GC/CT - , HIV -, PPD+/CXR-. Pregnancy was complicated by PIH, treated with Mag. ROM was 7 hours prior to delivery with clear fluid. Delivery was complicated by tight nuchal cord, cut before delivery. Apgars 3 and 9. Baby received PPV for 30 seconds to improve color and tone.

Baby has been doing well since birth, breastfed x3, stool x 1 and void x 1, VSS. Mom states that feeding are going well, but she complains of sore nipples.

FH: sibling under bili lights for 2 days in newborn nursery, negative for congenital diseases, childhood deaths, or atopic diseases.

SH: intact family, 3 yo sib; has all baby needs including car seat. Plans to receive care at LPCH clinic.

PE: wt - 3578g, length - 49.5cm, OFC - 34cm, temp 36.7 - 37.1, HR 145 - 160, RR 48 - 52

gen - well appearing, NL tone/color/activity, crying with exam

skin - no jaundice, + red macules with central papules scattered on chest and legs

HEENT- normocephalic, + fluctuent area over R parietal bone, does not cross sutures, + RR B eyes, ears NL set/shape, palate intact, tongue WNL

neck - WNL, clavicles intact B

lungs - clear B, - G/F/R

CV - RRR without m, pulses +2 B

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump intact/clamped

genitalia - NL male with testes descended B, anus patent

ext - hips stable B, all WNL

neuro- NL suck, grasp, Moro reflexes, DTRs +2 B

A/P: Term AGA newborn with low first apgar, with erythema toxicum rash and R parietal cephalohematoma. Mom with soreness during feeds.

Expect spontaneous resolution of rash within 1 -2 weeks

Expect spontaneous resolution of cephalohematoma, but follow clinically for jaundice, TBili to be drawn at 24 hours of life with newborn screen.

Discussed with mom expectations for feedings, RN to help with latch technique and position, recommended BF class.


Susan Student, MS 3, pager 19790

CoSignature of MD

2/9/08 08:15

MS Progress Note

ID: Term AGA male, DOL #2

S: baby did well O/N, mom reports much less pain with feedings

O: VSS, BF x 11, void x 2, stool x 5 (mec), TB at 26 hours of life - 6.5, algo was passed B

PE: wt - 3408g (down 5% from BW)

gen - well appearing, NL tone/color/activity, awake and alert

skin - mild facial jaundice, + red macules with central papules scattered on chest, abd, and legs

HEENT- normocephalic, + fluctuent area over R parietal bone unchanged from yest, + RR B eyes, ears NL set/shape, palate intact, tongue WNL

neck - WNL, clavicles intact B

lungs - clear B, - G/F/R

CV - RRR without m, pulses +2 B

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump intact/dried

genitalia - NL male with testes descended B, anus patent

ext - hips stable B, all WNL

neuro- NL suck, grasp, Moro reflexes, DTRs +2 B

A/P: Term AGA male, DOL #2, now feeding better, with mild jaundice/cephalohematoma and TBili low int. risk on Bhutani graph.

Follow jaundice clinically, consider repeat TB in am if exam worsening.

Routine care.


Susan Student, MS 3, pager 19790

CoSignature of MD