Writing Notes (Guide during internship)

This file is a guide, and by no means is a reference, you should refer to other resources as your main reference.

Done by:
Dr. Maha AlGhamdi
Dr. Mohammed Baqais
Dr. Nada AlSomali

Internship Program 2022/2023, KSU, Contact us at:

[email protected]

Internship Program 22/23 Presidents, your colleagues : Abdullah AlSaeed & Aseel Badukhon

***

One of the challenges the interns face during their training is how they present their patients
in rounds and how they should be writing proper notes, and to help them progress during their
training, this guide was created.

This file contains:

➔ General tips
➔ Types of notes
➔ General structure (SOAP)
➔ Internal medicine
➔ Emergency
➔ ICU
➔ Surgery
➔ Pediatrics
➔ OBGYN
General tips
Note writing is an essential skill that any physician or healthcare professional should acquire
and be keen about, as it is a reflection of a patient's illness severity and delineates treatment
plan. And to be good at it, you need commitment and continuous training with proper feedback
from your seniors. Here you can find general tips for writing notes, and keep them in your mind
as you are reading the remaining file:
● Accurate and up to date
● NOT COPIED from anyone
● Limit repetition (do not state PMH in HPI and in PMH section)
● Put things in the right place. Do not put data in the HPI or Assessment. Put it in the
data section.
● Remember notes should be narrative and educational
● Avoid inappropriate abbreviations (i.e.: 2/2 for secondary to or WWP- warm and well
perfused)
● Remember to update health issues on an ongoing basis
● Do not argue in the chart- if you disagree with another service resolve this outside of
the medical record

Types of notes

Admission

Progress

Discharge

Referral

Consult

General structure
 - This is a good general structure with explaining each section, please use it for your
reference:
https://drive.google.com/file/d/1mUFZnHn-I06qFlRZx-UOU0_yXHEwBPRj/view?usp=dri
vesdk
- This is SOAP:

***

Internal Medicine
1.Writing notes:
Admission Note

(Name)is (Age)+(gender) old known to have:

 (comorbidities,Past medical history and surgical history)

- First, start with the medical things then surgical organize it from the newest one to the
most previous one and then allergy
- Any history of ICU or ward admission with the reason for admission (Add it if is
significant to the current condition and it will direct our management plan and the
patient’s prognosis)

Functional states:
What can the patient do? Bedbound or not? (You should know the patient's baseline)

Code status:
Full code or DNR with net or DNR without net etc

HPI (History of presenting illness):

SOCRATES

- The associated symptoms that go with the chief complaint’s system or are connected to
it should be mentioned first like abdominal pain, nausea, vomiting, but an unrelated
system that doesn’t seem to be connected to the chief complaint can be listed with the
systematic review section.
- Don’t forget the constitutional symptoms: fever, weight loss appetite, sweating and
loss of weight.
- Significant negative and positive and (ask Questions to roll in or roll out DDX write it as
important positive and negative)

Review of systems:

Hospital course:
- Mention the ER course including everything that has been done by them including the
labs and investigations with the results.
- Mention the ICU course if present:
Patient presentation and physical examination during that time and how did they dealt with it,
how they managed the patient “investigations and treatment”, and then the patient response.

For example, for management:

- Oxygen requirement on that time was on what (Nasal cannula or face mask) ,how many
Liters
- medications received, which continue IV Fluids etc.
 - investigation Labs, imaging, Culture
- reassessment for Patient and patient response at that time

Home medications:
- Name of the medication, frequency each day (BID, TID, once), and the route.

Seen By our team:

Vitally:
-Is there a fever or not any spike? Febrile or afebrile? If there is fever
-Respiratory Rate, tachypneic or not? Pulse rate, tachycardia or not?
-BP Range if non stable or normotensive if the patient normotensive
-Oxygen saturation by percentage %? On room Air or face mask or nasal cannula etc.. and how
many L if the Patient is on a Face mask or nasal cannula, etc.
Clinically:
- Does the patient look well or sick, in distress or not?
- Diet (NPO, Liquid, Soft, regular) and why? Does the patient eat? Does the patient
tolerate orally no nausea, vomiting, or coughing after eating? If there is vomiting:
Appearance, amount, whether there is blood or not, color, content, frequency, projectile
or not, etc.
- Passing bowel motions
- Urination (FUN WISE) foley catheter? If wearing a diaper or not?

Physical Examination:
Depend on each patient and what you should focus on (Mentioned here is the most common
findings, there are many things you can see in your patients)

1.General:
- The patient looks well or sick, in distress or not, by saying the type of distress, for
example, moderate subcostal retraction, etc.
- Oriented to Time, Person, and Place (TPP). If not, assess the GCS score, and you should
know the patient's baseline at home if the patient is not oriented to TPP. Maybe this
low GCS Score is normal for his or her baseline!
- If The patient Looks pale or cyanosed or not? Any deformity?

2.Hydrating statues:
Moist or dry mucus membrane, CR <2 sec or more

3.CVS:
JVD or not? Equal or not? Bilateral pulse grade (?) regular or irregular rate and rhythm,
audible S1 and S2 is there a murmur or not (describe if any)? Any limbs edema, pitting or
non-pitting edema, then describe it (extend to where and grade of edema)?

4.Pulmo:
Equal bilateral air entry or not? Are there any added sounds (crackle or wheezing crepitation
etc.. then where)?

5.Abdomen:
Symmetrical abdomen contour or asymmetrical? Distension? Ascites if there is distention? Any
tenderness? if yes where then severity (Mild or moderate or severe)? Any rigidity or rebound
tenderness? PR examination if a patient has hematochezia or melena also describe the area?

Active issues:
- Then (problems list= active issue) (you should rank your problems form most serious or
concerning one to least one )
- My active issue that include (labs,complaint ,Diagnosis)

For example:

Problems list: —————

1-(active issue):

Follow SOAP

Subjective:

- Any thing happen regarding this active issue since you be responsible for the case
- Team action=patient response (patient on lasix 80 IV and his SOB improved and Urine
output .....)
- Procedure
- New complain for same active issue (for example CKD patient stage 5 develop uremic
symptoms)
- Consultations response from other teams

Objective:

- Relevant exam (examination findings?)

- Relevant labs: interpretation only
 - Relevant imaging :interpretation only no need to read it
- Relevant culture

(If you do not know which relevant ask for help) 🌟

And the remaining issues should follow the same sequence..

Assessment:

- This includes (Name) +(age)+(gender)+(reason for admission )+(improving or worsening

or in plateau phase after your interventions)

Plan:

- Write a very very clear plan with the details

- The case was discussed and seen with (senior Doctors name)
- to start new medication
- consultation
- investigations
- etc ....

Progress Note

(Name) is (age) years old (old man or lady or old female, Gender) known to have:

- (comorbidities,Past medical history and surgical history)

- First, start with the medical things then surgical organize it from the newest one to the
most previous one and then allergy
- Any known history of ICU or ward admission with the reason for admission. (Add it if is
significant to the current condition and it will direct our management plan and the
patient’s prognosis)

Functional status:

(--------) what can the patient do? Bedbound or not? (You should know the patient's baseline)

Code:
Full code or DNR with net or DNR without net etc..

Admitted through (ER or ICU or elective admission?) on (date) as case of

(-------------)secondary to (---------) under( your team )

- And a brief history about the patient day after the admission because the patient's
condition is not known that much to your team then after that other day you can ignore
this part. Going directly to below section

Currently on:

- Name of medication, dose, the frequency (BID, TID,Once) or Q how many hours, and the
route. PRN(mean when need it only) or Regular medication

Q12h = BID
Q24h = once
Q8h = TID

For example:
1) Ceftriaxone 400 mg IV (q12 hourly=BID one of them enough to write it) day 6/7
2) For any PRN medication mention whether the patient took from it and for what

Seen Today:

Vitally:
- Is there a fever or not any spike? Febrile or afebrile? If there is fever, how many spikes?
What is the Tmax?
- Respiratory Rate, tachypneic or not?
- BP Range 24h or normotensive if the patient normotensive
- Oxygen saturation? On room Air or face mask or nasal cannula etc.. and how many L if
the Patient is on a Face mask or nasal cannula, etc. +- BIPAP for how many (hours?) on
and (hours?) off

Clinically:
- Does the patient look well or sick? in distress or not?
- Diet (NPO, Liquid, Soft, regular) or NGT and why?? Does the Patient eat? Does the
Patient tolerate orally no nausea, vomiting, or coughing after eating? If there is
vomiting: Appearance, amount, whether there is blood or not, color, content, frequency,
projectile or not, etc.
- Passing bowel motions
 - Urination (FUN WISE)?, On foley catheter? On diappers?
- Mobilization?
- Any new complaints ? For any new complaint take a full detailed history regarding it
like in the admission note but be organized) then add it to Problems list section below

Physical Examination:
Depend on each patient and what you should focus on (Mentioned here is the most common
findings, there are many things you can see in your patients)

General:
- The patient looks well or sick, in distress or not, by saying the type of distress, for
example, moderate subcostal retraction, etc.
- Oriented to Time, Person, and Place(TPP). If not, assess the GCS score, and you should
know the patient's Baseline at home if the patient is not Oriented To TPP.
- If The patient Looks pale or cyanosed or not? any deformity?

Hydrating statues:
Moist or dry mucus membrane, CR <2 sec or more

CVS:
JVD or not? Equal or not? Bilateral pulse grade (?) regular or irregular rate and rhythm,
audible S1 and S2 is there a murmur or not (describe it if any)? Any limbs edema, pitting or
non-pitting edema, then describe it (extend to where and grade of edema)?

Pulmo:
Equal bilateral air entry or not? Are there any added sounds (crackle or wheezing crepitation
etc.. then where)?

Abdomen:
Symmetrical abdomen contour or asymmetrical? Distension? Ascites if there is distention? Any
tenderness? if yes where then severity (Mild or moderate or severe)? Any rigidity or rebound
tenderness? PR examination if a patient has hematochezia or melena also describe the area?

Problems list:

- Then (problems list= active issue) (you should rank your problems form most serious or
concerning one to least one )
- My active issue that include (labs,complaint ,Diagnosis)
1-(active issue):

Follow SOAP

Subjective:

- any thing happen regarding this active issue for last time you see the patient (For
example during oncoll)
- Team action=patient response (patient on lasix 80 IV and his SOB improved and Urine
output .....)
- Procedure
- New complain for same active issue (for example CKD patient stage 5 develop uremic
symptoms)
- Consultations response from other teams

Objective:

- Relevant exam
- Relevant labs interpretation
- Relevant imaging :interpretation only no need to read it
- Relevant culture

🌟
(if you do not know which relevant ask for help)

And the remaining issues should follow the same sequence..

Assessment:

- Which include(Name)+(age)+(gender)+(reason for admission)+(improving or worsening

or in plateau phase, after the last time you see the patient)

Plan:

- Write a very very clear plan with details

- The case was discussed and seen with (senior Doctors name and Consultant)
- to start new medication
- consultation
- investigations
- etc ....
Patient care:

- On DVT prophylaxis?

Any Patient should receive DVT prophylaxis except if there are contradictions to using it, you
should know the type of DVT prophylaxis your patient use but not write it in the note

- If a patient is known to have DM on insulin, how many units? Fasting glucose and
post-meal glucose to adjust the dose according to reading, you should not write
glucose level in the note look to it in the system according to that adjust the dose

Discharge Note

Discharge Summary

Admission Information

Date of admission: May 11, 2022

Admitting Physician :

Reason of admission: (Acute decompensated heart failure secondary to non-compliance.)

Discharge diagnosis: (-----)

Co-Morbidities:

For example:

Ms.X is 64 years old lady with:

- DM II on insulin aspart and langurs with latest HgA1c 7.5 with diabetic nephropathy

- HTN on Adalate 90 mg, controlled following with PCC

- Dyslipidemia on Atorvastatin
- Chronic Kidney disease, Stage V, following with King Fahd Medical City

- IHD S/P PCI to LAD (~4years ago in Saudi Germany hospital) on Aspirin and plavix, following
with cardiology with EF 40% Oct. 2019

HPI:

Copy and paste HPI which in Admission note

Hospital Course (Issue addressed):

(Problem based then day by day for each Problem)

For each day: What has been provided? Consultations? Any major events happened during
admission?

1. ADHF due to non-compliance to medication:

By chronological order or summarize what happened in one Paragraph

For example:

day 11/5:

Then your wright what did you do

Day 12/5:

Same

2-Hyperkalemia:

Day 11/5:

—------

Day 12/5:

Discharge Medications:
Divided to three-part
1-Medications we stopped
2-medications we change it
3-Medications we started

Vitals & Measurements: (day of discharge)

BP 151/52 RR 22 Pulse rate:78 T: 36.6

Physical Examination :(day of discharge)

Laboratory:(day of discharge)

Interventions and Procedure: Non.

Discharging Physician : Dr excellent .

Referral and appointment:

She has booked an appointment with cardiology next month. Follow up with nephrology on
July 27

Patient Discharge Condition :

Clinically well and vitally stable. Discharge Disposition: Home, depend on location write

Plan:(write a very very clear plan with details)

2.Presenting during rounds:

Same as The progress note, the only difference is:

- Important things to compare labs or chest X-Ray etc., day after day physical
examination. For example yesterday there was moderate wheezing bilaterally and
moderate subcostal retraction. Today no wheezing, there was a mild subcostal
retraction, and I examined the patient after salbutamol for 4 hours. I think this patient
ready for spacing salbutamol to 6 hours
- The patient care section, you should not say it during the round
Emergency
1.Writing notes:
Chief complaint :————
HPI
Age, sex , medical and surgical hx

Example
77 years old male known case of
-HTN
-ESRD
-S/p cholecystectomy on 2021 at Alhabib hospital

- Presented to ED with a hx of ——— for —-

- Explain the events leading up to the complaint example: knee pain: yesterday pt fell
from one step and landed on his Lt knee , after that pt was able to get up and bare full
weight but was having knee pain, at midnight his pain worsened and he noticed
swelling and was unable to bare weight
- Details about the sx
- Important negatives as bullet points (ED physicians love their bullet points)
- Hx of previous episodes, and how was it managed

Review of systems
It’s very important in the ED
Mention 2-3 major sx from every system

Physical exam
Start with general, you know the drill
-Alert, Conscious and oriented
-Vitally stable, afebrile, pt is laying on the bed comfortably, looks well, not in pain or distress
(A lot of ED pts look sick, don’t just write this automatically) example: pt looks lethargic, pt
looks short of breath, Pt looks pale and dehydrated, Pt is in pain
- start with the system involving the chief complaint
- Then for each pt you must do: CVS, respiratory, abdominal

Reassement
Mention how the pt is doing when you reassess them compared to when you saw them upon
presentation
Example: pt’s pain improved,pt’s O2 requirements increased from 1l to 3L , pt feels better his
nausea and vomiting improved and tolerated drinking water……
Plan:
Discussed with dr——
- Pt was given clear instructions on when to come back to the ED
- Write Rest of the plan as discussed with the team

Trauma note

Primary survey
A: can talk? Can handle secreations, on C collar
B: breathing spontaneously, good equal bilateral air entry.
C: no active External bleeding, distal pulses are palpable, stable pelvis
D: alert conscious oriented, moving all limbs, GCS 15/15, pupils are normal in size and equally
reactive
E: exposed, logrolling was done, no tenderness or palpable step off or gabs

E- FAST negative
CXR unremarkable

Secondary survey
AMPLE
A: no allergies
M: not on any medications
P: previously healthy
L: last meal 8Am today
E: high mechanism MVA, 120km/h, Fasten seatbelt, unrestrained,impact ( front,rear or side), no
roll over, airbag was not deployed, not ejected, no history of LOC, amnesia, no vomiting, no
seizure, no deaths at the scene

Head: No lacerations or tenderness, no depressed fracture

Ear: no otorrhea or bleeding no hemotympanum
Nose: no septal hematoma, no tenderness, no active bleeding
Neck: no hematoma, or midline tenderness
CVS: normal S1+S2 no added sounds
Chest: equal air entry bilaterally
Abdomen: soft and lax, no localized tenderness
MSK: all of upper and lower limbs: no obvious deformity or laceration, normal or ROM of all
joints neurovascular: intact
CNS: grossly intact
ICU
1.Writing notes:

Progress Note

Date and Time of Service:

O/N Events:

SUBJECTIVE:
OBJECTIVE:
BP:
MAP:
Pulse (art /cuff):
RR:
O2sat:
Tm/Tc:
BG:
I/Os:
Bal:
UOP:
Drains:
Ventilator Mode:
Vent rate:
Tv:
PIP/Pplat:
PEEP:
PS:
FiO2:

Physical Exams
Gen:
Neuro:
HEENT:
Resp:
CV:
Abd:
Ext:
Skin:
Lines:

Labs, Micro, Imaging/Studies

Labs:
Micro:
Radiology / Studies:
Lines / d # :

Meds:
Drips:
Prophylaxis:
IVF
Diet:

ASSESSMENT / PLAN:
___ year old ___ with….
[From head to toe]
Neuro (& Psych):
Endocrine:
Cardiovascular:
Pulm / Resp:
Gastrointestinal:
Genitourinary:
Hematologic:
Infectious Disease:
Musculoskeletal
Dermatology:
FEN:

This was taken from an online resource as not all interns had a rotation in ICU.

🚩The following guide can help you through your ICU rotation, it is HIGHLY RECOMMENDED:
https://drive.google.com/file/d/1AjER9L-kxRq4F7J4t-wsWrVdm3Gx1e8w/view?usp=drivesdk
👋 Also, this article done for interns (R1 in US) to help them understand the basis of
presenting in MICU:
https://medchiefs.bsd.uchicago.edu/resources/service-specific/interns-rough-guide-micu/

Surgery

1.Writing notes:

Admission Note
Subjective:

The chief complaint, Reason for admission and date

Personal information, HPI:

Age + gender + any known diseases. You can write any other relevant personal information like
the job/place of living.
More details about the symptoms, other related symptoms and what has been provided to
control/treat these symptoms and where (which hospital)

Surgical, Family, Medication hx:

Previous surgeries + family hx of related diseases or similar/same disease + related
medications (if the pt is compliant to his meds or not)

Seen today:
How is the pt doing today in terms of: Pain? Walking? Fasting? Any other complain? current
medications: Especially active abx, dose and the day? On anticoagulation or not and what type?

Review of the other systems:

In case you missed any complain the patient might have

Objective:

Physical examination:
Vitals trend
Write the relevant examination including General/Abdomen/Chest/Lower limb/Upper limb.
Recent labs, especially (hgb, wbc, esr, crp, K, Na, creatinine, BUN, glucose) Microbiology and
urinalysis if there is.

Assessment:
Write a summary of the case (brief hx) + reason of admission

Plan:
For OR (Name of the surgery) + Site + date.

Progress Note
Subjective:

Personal:
Age + gender + any known diseases (K/C). You can write any other relevant personal
information like the job/place of living

The chief complaint, Reason for admission, HPI:

Presenting symptoms, more details about the symptoms and other related symptoms. What
has been provided to control/treat these symptoms and where (which hospital)

Surgical, Family, Medication hx:

Previous surgeries + family hx of related diseases or similar/same disease + related
medications (if the pt is compliant to his meds or not)

Post-Op:
What was the procedure the patient had during his admission and how many days
post-surgery

Seen today:
How is the pt doing today in terms of: Pain? Drain output and color? Catheter output? Walking?
Eating/diet (clear liquid? Soft? Regular??) and if tolerating or not (no nausea or vomiting)?
Leg/chest pain/SOB to r/o PE? Passing stool or flatus? using incentive spirometry? Any other
complaints?

Review of the other systems:

in case you missed any complain the patient might have

Objective:
Physical examination:
Vitals trend
Examination of wound site and dressing status
Write the relevant examination including General/Abdomen/Chest/Lower limb/Upper limb.
Recent labs, especially the pre op and post op (hgb, wbc, esr, crp, K, Na, creatinine, BUN,
glucose) and compare to previous. Microbiology and urinalysis if there is.

Assessment:
Write a summary of the case (brief hx) + reason of admission

Plan:
This can be given earlier in the morning round or if there's any update it'll be modified by the
co-signing resident.

Discharge Note
Subjective:

Date of admission, Date of discharge

The chief complain, Personal information, HPI:

Age + gender + any known diseases. You can write any other relevant personal information like
the job/place of living.
More details about the symptoms and what has been provided to control/treat these
symptoms and where (which hospital)

Surgical, Family, Medication hx:

Previous surgeries + family hx of related diseases or similar/same disease + related
medications (if the pt is compliant to his meds or not)

Hospital course:
What has been provided? Consultations? Any major events happened during admission?

Seen today:
How is the pt doing today in terms of: Pain? Walking? Eating/diet (clear liquid? Soft? Regular??)
and if tolerating or not (no nausea or vomiting)? Leg/chest pain/SOB to r/o PE? Passing stool or
flatus? using incentive spirometry? Any other complaints?

Review of the other systems:

in case you missed any complain the patient might have

Objective:

Physical examination:
Vitals trend
Write the relevant examination including General/Abdomen/Chest/Lower limb/Upper limb.
Recent labs, especially (hgb, wbc, esr, crp, K, Na, creatinine, BUN, glucose) Microbiology and
urinalysis if there is.

Discharge condition:
Stable/healthy condition or not?

Assessment:
Write a summary of the case (brief hx) + reason of admission

Plan:
This can be given earlier in the morning round or if there's any update it'll be modified by the
co-signing resident.

2.Presenting during rounds:

You only present the progress note
- Start with the name of your pt and Personal information including (k/c)
- Talk about the chief complaint and what surgery had been done and what day is it now
- Then move to the seen today part
- What medication the pt is on
- Then talk about the physical examination and labs. (don’t forget to compare the labs to
the previous ones)

Pediatrics
1.Writing notes:

Admission note

- (Name) is (age) days/Months/Years old ( Boy or Girl) + (Full term or preterm if preterm
 which weeks?) + (SVD or CS and Why) known to have (Comorbidities if a Patient has),
and you would list them as follows:

Sara is a 10 year old girl who is known to have:

1) Diabetes mellitus type 1, diagnosed at the age of 6 years

2) Crohn's disease, diagnosed at the age of 5 years
3) Iron deficiency anemia on oral Iron supplements

Tip: you can mention the medications for each condition there ^ or with the home
medications section.

- Any known history of ICU or Ward admission and why?

Functional status:

(--------) what can the patient do? Bedbound or not? (You should know the patient's baseline)

Code:

Full code or DNR with net or DNR without net etc..

History of presenting illness HPI:

- Eg: Sara is a 4 months old baby girl who is previously healthy came to the emergency
department with fever and abdominal pain for 1 week
- (Each symptom should be further described and written in full details like in vomiting
we ask about the quantity, projectile or not, color, contents, blood or blood clots,
frequency, aggravating and relieving factors, timing..etc, the same idea applies to other
symptoms)

SOCRATES , then you would elaborate more on the chief complaint and describe it in detail,
it’s like you’re telling a story, but we have to be organized with the correct timeline.

- The associated symptoms that go with the chief complaints system or are connected to
it should be mentioned first like abdominal pain, nausea, vomiting, but an unrelated
system that doesn’t seem to be connected to the chief complaint can be listed with the
systematic review section.
- Then important negative you should mention it to exclude other DDX

- Don’t forget the constitutional symptoms: fever, weight loss appetite, sweating and
loss of weight.
Important pediatric symptoms that should be mentioned if present or referred to as
negative: Activity, sleep and feeding.

Hospital Course:

- Mention ER course or ICU course if present:

Patient presentation and Physical Examination during that time and how did they deal with it
(investigations and management ) then the patient response (improving or worsening ) then
the course after that

For example, for management:

- Oxygen requirement on that time was on what(Nasal cannula or face mask) how many
Liters
- Medications received, which continue IV Fluids etc.
- Investigation Labs, imaging, Culture
- Reassessment for patient
Home medications:
● Name of medication, dose, for how many times each day use this(BID, TID,Once), and
the route
Nutritional history:
● Mention the feeding history and how many ml is the baby taking if applicable and the
frequency. Breastfeeding or formula feeding if both what is more?
● Mention the type of diet and food he’s eating.
● Saying that sharing a family's diet is not enough, what is a “family’s diet”?

Developmental History:

● The milestones he gained and commenting on all domains.

● At what age does his milestones stand?

Social History:

● Where do they live?

● How many household members?
● Is there a maid / housekeeper?
● Who does the child live with and who is the primary caregiver? mother working or not?
● Socio-economic status?
● History of recent travel (If the case was infectious this should be in the HPI, in general
anything that is related to the case should be written in the HPI as well).
● Pets at home?
● Smoking and alcohol?
● Where are they originally from

Family history:
 ● Are the parents related? How many brothers and sister does the patient have, should
be written like this eg:
- A 5 year old sister who is healthy
- A 4 year old brother who has asthma.
● Then mention if the mother or father of any other relatives have any medical issue or
disease.
● Malignancies in the family and chronic diseases.
● The ages of both the mother and father.

Antenatal / postnatal history:

- Eg: The baby was born at term 39 weeks via SVD with no complications. CS or SVD if
CS, what is the reason?
- The maternal history should be mentioned including medications taken during
pregnancy and any infections during pregnancy including UTI.
- Was the baby admitted to the NICU? And why? And for how long?

Medical History:

Any medical illness that the patient currently has and any previous admissions and
transfusions.

Allergies:

Mention them and what happens when the baby is exposed to the allergen.

Surgical history:

Any previous surgeries?

Seen Today By Our team:

Vitally:
- Is there a fever or not any spike? Febrile or afebrile? If there is fever, how many spikes?
What is the Tmax?
- Respiratory Rate, tachypneic or not? Pulse rate, tachycardia or not?
- BP Range or normotensive if the patient normotensive
- Oxygen saturation? On room Air or face mask or nasal cannula etc.. and how many L if
the Patient is on a Face mask or nasal cannula, etc.

Clinically:
- Does the patient look well or sick? in distress or not?
- Diet(NPO, Liquid, Soft, regular) or NGT and why?? Does the Patient eat? Does the
Patient tolerate Orally no nausea, vomiting, or coughing after eating? If there is
 vomiting: Appearance, amount, whether there is blood or not, color, content, frequency,
projectile or not, etc.
- Passing bowel motions
- Urination ?On a foley catheter?
- Level of activity? Quality of Sleep?
- Any new complaints since the patient came? For any new complaint take a full detailed
history regarding it

Physical examination:
Depend on each patient and what you should focus on (Mentioned here is the most common
findings, there are many things you can see in your patients)

General:
The patient looks well or sick, in distress or not, by saying the type of distress, for example,
moderate subcostal retraction, etc. Oriented to Time, Person, and Place(TPP)depend on his or
her age. If not, assess the GCS score and activity, and you should know the patient's baseline
at home. If The patient Looks pale or cyanosed or not? any deformity?

Hydrating statues:
Moist or dry mucus membrane, CR <2 sec or more than that

CVS:
JVD or not?, Equal or not? Bilateral pulse garde (?)regular or irregular rate and rhythm, Audible
S1 and S2 there is murmur or not? Any limbs edema Pitting or non-pitting edema, then write
extend to where and grade of edema?

Pulmo:
Equal bilateral air entry or not? There are any add sounds(crackle or wheezing crepitation etc..
then where)?

Abdomen:
Symmetrical abdomen contour or asymmetrical? Distension? Ascites if there is distention? Any
tenderness? if yes where then severity Mild or moderate or severe? Any rigidity or rebound
tenderness?PR examination if a patient has hematochezia or melena and describe the area?

Active issues:

- Then (problems list= active issue) (you should rank your problems form most serious or
concerning one to least one )
- My active issue that include (labs,complaint ,Diagnosis)
For example:

Problems list:

1-(active issue):

Follow SOAP

Subjective:

- Any thing happen regarding this active issue since you be responsible for the case
- Team action=patient response (for example we gave him 3 back to back Salbutamol
and his SOB improved)
- Procedure
- Consultations response from other teams

Objective:

- Relevant exam findings

- Relevant labs: interpretation only
- Relevant imaging :interpretation only no need to read it
- Relevant culture

(if you do not know which relevant ask for help)

And the remaining issues should follow the same sequence.

The case was discussed and seen with (senior doctors names)

Assessment:

(Name)(Age)(Gender) (Known to have …)(admitted as case of ….) (Vitally and clinically describe
the patient situation)

Plan: (write a very very clear plan with details)

1)To start the patient on 400 mg ceftriaxone for a total of 7 days to cover this and that pending
the culture results.
 Progress Note:
- (Name) is (age) days/Months/Years old ( Boy or Girl) +(Full term or preterm which
weeks if preterm)+(SVD or CS and Why) known to have:
- comorbidities
- Any known history of ICU or Ward admission and why?

Functional status: (--------) what can the patient do? Bedbound or not? (You should know the
patient's baseline)

Code: Full code or DNR with net or DNR without net etc..

Admitted on (date) as case of (-------------)secondary to (---------) under (your team write

it here)

- And a brief history about the case the day before the admission because the patient’s
condition is not known that much in your team then after that other day, you can ignore
this part and go directly to the below section.

Currently on:

- Medication name, dose, for how many times per day(once,BID, TID) or ?Q for every how
many Hours per day ,Route , (PRNmean when need it only or Regular medication do not
mention this on note just know it i mean PRN Or regular)
- IV fluids type? rate?

For example:

-Salbutamol q4h

-levothyroxine 75mg once

-lisinopril 20mg orally BID

-PRN (mean when need it only and by patient request ) paracetamol for pain or fever etc… and
mention if the patient took or not

Seen today:
Vitally:

Vitally stable or if patient sick you should say it like this:

- Febrile or afebrile if there is fever spikes then what theT max and how many spikes last
24h
- respiratory rate and heart rate (range 24hs for it),Respiratory Rate, tachypneic or not?
Pulse rate, tachycardia or not?
- BP range 24hs or normotensive if patient normotensive
- Oxygen sat + (room air or nasal cannula or simple mask etc…if on anything on how
many Liters?)

Clinically:

- Patient look well or sick? In distress or not ?? improving

- a new complaint?? For any new complaint take a full detailed history regarding it like in
the admission note but be organized
- Then plus and minus depend on my case if indicated to write it:
1. Diet (NPO,liquid,soft) why?? Does the patient eat? Does the patient tolerate Orally no
nausea, vomiting, or coughing after eating? If there is vomiting: Appearance, amount,
whether there is blood or not, color, content, frequency, projectile or not.
2. passing BM
3. Mobilization or level of activity comparing to normal status activity
4. urination,foley catheter? toilet trained ?
5. Quality of sleeping?

Physical examination:

Depend on each patient and what you should focus on (Mentioned here is the most common
findings, there are many things you can see in your patients)

General:

The patient looks well or sick, on distress or not with saying the type of distress, for example,
there is a moderate subcostal retraction, etc. the patient Oriented to Time, Person, and
Place(TPP). If not, assess the GCS score, and you should know the patient's Baseline at home
if the patient is not Oriented To TPP; if The patient Looks pale or cyanosed or not? Any
deformity? On foley catheter urine Output for 12 Hours? Then adequate urine output or not?
Hydrating statues:

Moist or dry mucus membrane, CR <2 sec or more than that

CVS:

JVD or not?, Equal or not Bilateral pulse? Garde (?)regular or irregular rate and rhythm, Audible
S1 and S2 there is murmur or not? Any limbs edema Pitting or non-pitting edema then extend
to where and grade of edema?

Pulmo:

Equal bilateral air entry or not? Are there any added sounds(crackle or wheezing crepitation
etc.., then where)?

Abdomen:

Symmetrical abdomen contour or asymmetrical? Distension? Ascites if there is distention? Any

tenderness? If yes, what is the severity of the pain, Mild or moderate or severe? Any rigidity or
rebound tenderness?PR examination if a patient has hematochezia or melena also describe the
area?

Problems list:

1-(active issue):

Follow SOAP

Subjective:
- any thing happen regarding this active issue form the last time you see your patient
- Team action=patient response (for example:we increased lasix from 20 IV to 40 IV and
his SOB improved and Urine output …..)
- anything happened during oncoll regarding this active issue and how did they deal with
it ?
- Procedure
- Consultation done from last time you see the pateint

Objective:
- Relevant exam compering to day before if it was abnormal the day before
- Relevant labs
 - Relevant imaging =interpretation only no need to read it
- Relevant culture

(if you do not know which relevant ask for help)

And the remaining issues should follow the same sequence.

The case was discussed and seen with (senior doctors names)

Assessment:

(age)+(gender)+(admitted as case of…. )+(improving or worsening vitally and clinically

comparing to days before)

Plan: (write a very very clear plan with details)

- To start new medication

- Consultation
- Investigations
- etc ….

Discharge Note:

Discharge Summary

Admission Information

Date of admission: May 11, 2022

Admitting Physician :

Reason of admission: Asthma exacerbation secondary to dust exposure

Discharge diagnosis:-----

Comorbidities:
X is 6 years old girl with Full term, SVD:

- DM I on insulin aspart and lantous with latest HgA1c 7.5

- asthma diagnosed at age of 3 years on Ventolin PRN
- eczema diagnosed before 5 years

HPI:

Copy and paste the HPI of the admission (YOUR NOTE):

She presented to our hospital on May 11, 2022 with worsening of SOB over 4 hours prior to
her presentation. She exposed to dust denied any history of Fever,Chest pain,Dizziness,sore
throat,decrease of activity or sleeping

At home she is on Ventolin PRN but did not work as usual

Hospital Course (Issue addressed):

(Problem based then day by day for each Problem)

X was hospitalized for 5 days due to Asthma exacerbation secondary to dust exposure

She was monitored for the following issues:

1. Asthma due to dust exposure:

You have two ways to write it. The first one is an example below.

Or by chronological order: what did you see and your thinking, labs, investigation, and medications? You
do it by order

For example:

day 11/5:

Then your wright what did you do

Day 12/5:

Same

Or

Summarized what did you do please see internal medicine part to get better idea

2. Type I DM:
Same before

Vitals & Measurements:

BP 151/52 RR 22 Pulse rate:78 T: 36.6 for discharge day

Physical Examination :for discharge day

Laboratory: Labs of Discharge Day RBC 3.7

Hb 10.4

MCV 88.3

Scr 400 BUN 34.5 HCO3 25 Mg 0.98 K:4

Discharge Medications:
Divided to three-part
1-Medications we stopped
2-medications we change it
3-Medications we started

Interventions and Procedure: Non. Discharge Plan

Discharging Physician : Dr excellent .

Plan:

Referral and appointment:

There is an appointment with a general pediatrician next month (mention reason of follow up)

Patient Discharge Condition :

Clinically well and vitally stable.

Discharge Disposition: Home.

2.Presenting during rounds:

Same as The progress note, the only difference is:
- Important things to compare labs or chest X-Ray etc., day after day physical
examination. For example yesterday there was moderate wheezing bilaterally and
moderate subcostal retraction. Today no wheezing, there was a mild subcostal
retraction, and I examined the patient after salbutamol for 4 hours. I think this patient
ready for spacing salbutamol to 6 hours
- The patient care section, you should not say it during the round

OBGYN
1.Writing notes:
Obstetrics:
There’s 2 types of pts:
Antenatal and postnatal

Antenatal Note:

Start with basic info

— years old lady g—-, p—- at —— weeks of gestation by ( LMP or EDD or early scan it will be
mentioned in previous notes) known case of ——
Was admitted on —- through ( ED or clinic) as a case of (admitting diagnosis) for ——- ( reason
of admission e.g monitoring, CS, induction of labor, investigation)

Medical hx: the disease and what medication she’s taking for it and mention the pre pregnancy
dose if it’s different and how she was being managed pre pregnancy e.g known case of DM on
metfomin was on diet pre pregnancy , hypothyroid on thyroxine 75mg pre pregnancy dose
50mg
Surgical hx: surgery, when, where
OB hx: g—-, p—- +—
G1: SVD or CS(if CS mention why), term or not complications ( GDM, pre eclampsia,…) , how’s
the baby ( baby alive and well
If it’s an abortion mention in which trimester and how was it managed ( medically or surgically)
G2:
G3;
Current pregnancy: spontaneous or IVF,

Seen today
Fetal movement (good or reduced)
Abdominal pain
Vaginal bleeding or leaking
Any other complains the pt is having

Labs
Hgb
GTT
Blood group
Rubella status
GBS

US
Put the report of the last ultrasound and at which week was it done

Physical exam
Vitals
General: pt is laying on bed completely, looks well, not in pain or distress bla bla
Abdominal examination :
CTG:

Assessment and plan

Write the plan as discussed in the rounds and make sure to always mention discussed with “
the most senior in the rounds”

Postnatal Note:

Postnatal
A_year old lady , medically _ and surgically_ ,
p_+_ ,
post_ CS / SVD day (1/2/3)
Estimated blood loss during opration : _
findings : _

Patient is seen today ( subjective )

Patient is seen with the team
Has no complain , fine
Tolerating orally
Passed urine and flatus
Lochia normal
Breast feeding her baby
moblizing

Physical Exam :
O/E: vital/signs stable, afebrile.
conscious, alert, lying comfortably on the bed.
Abdomen: soft lax, no tenderness

Well contracted uterus ?

normal lochia
lower limb: no sign of DVT

(If CS : wound dressing removed wound clean dry no oozing no bleeding no gapping)

Labs:
Rubella _
hgb _ ( pre ? Post ?
Rubella status
Blood group:
OGTT
Normal fasting :5.1
One hour : 10
2 hour :8.5

Plan:
Discussed with dr ————
2.Presenting during rounds:
Same as the note

Best of luck (: