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Patient Tracker Help OME PDF
Patient Tracker Help OME PDF
Sticker:
Put the patient’s sticker here. You’ll have the name, account number (for dictating), and the MRN number (for looking the patient up in
the system).
Next to the sticker, keep the numbers that matter to you: the admit dictation number and the discharge dictation number (just in case
you do the work and someone says you didn’t. Rather than re-dictating, you can just say BOOM! here’s the number).
Finally, in this section list the consulting physicians – who is on the case with you? This matters most for the discharge summary.
H&P Essentials:
This is the chart review you get from previous H&Ps if they exist, or the mandatory info you need from the patient. It’s the past medical,
past surgical, social history, fam history, allergies, and medications.
Notice the short-hand, abbreviations, and truncated medication names. Coreg 25’’ means “Carvedilol 25 mg po bid”. Breaking that
down, coreg is shorter than Carvedilol (can use brands in the real world), oral is assumed unless written, and the ‘’ means bid.
SO LONG AS YOU KNOW WHAT IT MEANS, THAT’S ALL THAT MATTERS.
Also notice the white space. There are distinct columns between the headings. The CHF business sort of runs over into meds, but it
very intentionally lines up the dosages of medications. The methotrexate (MTX) is weird, so it doesn’t really fit. But that’s ok - for the
most part there are discrete columns. It’s crucial to make it look good with solid organization. The goal is to enable you to quickly
identify and pull data from the page on the fly. Spacing and white space is important.
Vitals and Physical:
This includes the vitals when you saw the patient in the ED. It can also include the original vitals and the change from original
presentation to the time you see them. But, NO RANGES. This is going to be for the H&P.
The physical isn’t all written out, you notice. Intentional - only the pertinent findings go here. You know what a normal exam is and how
to dictate it; there’s no reason to write out said normal exam in your tracker. Here we’re helping you hone in on what to talk about on
subsequent days – since the JVD was there day 1, you should probably mention it on day 2 and day 3.
© OnlineMedEd.org
© OnlineMedEd.org
You can actually reconcile medications. You have what they’re taking on the left, what they were taking on the right. Comparing
becomes possible. Most importantly, you can dictate - whether it’s the admit dictation (the right page) or the discharge dictation (the
right page + the active issues). Oh ya, and if / when they bounce back you’ll already have everything you need written here. Blamo
© OnlineMedEd.org
© OnlineMedEd.org
© OnlineMedEd.org