ADMISSION:

Patient was seen and examined.

Vitals signs was taken and recorded.

Patient was admitted as a case of (insert diagnosis here).

Diagnostics- Diagnostics were done. Results showed (insert pertinent lab/diagnostic

findings).

Patient was referred to Cardio service (noted order/and was advised for).

Diet- Patient was put on (insert type of diet).

IVF - Patient was started on (insert fluid management/ PNSS 1L to run for 6cc per hour)

Drip (esp in ICU) - Patient started on (insert medication/ Norepinephrine Drip)

Medications - Patient started with medications (antibiotics comes first on the list)

Miscellaneous - example: Patient was hooked to Oxygen support at 5 LDM/ nasal canula/ ;
Patient was hooked to mechanical ventilation (include setting)

Closing- Present management was continued. Patient was closely monitored throughout the
hospital day.

DAILY UPDATE

Patient was seen and examined.

Vitals signs was monitored and recorded.

Diagnostics- Diagnostics done and noted (insert pertinent lab/diagnostic findings).

Referral - Patient was referred to Cardio service (noted order/and was advised for).

Subjective - Patient with no subjective complaints/ complaints of (symptoms)

Objective - Patient noted with no (signs/symptoms cough, fever, dizziness).

NEW ORDERS (If with new orders: DIET to MISCELLANEOUS)

Diet- Patient was put on (insert type of diet).

IVF - Patient was started on (insert fluid management/ PNSS 1L to run for 6cc per hour)

Drip (esp in ICU) - Patient started on (insert medication/ Norepinephrine Drip)

Medications - Patient started with medications (antibiotics comes first on the list)

Miscellaneous - example: Patient was hooked to Oxygen support at 5 LDM/ nasal canula/ ;
 Patient was hooked to mechanical ventilation (include setting)

CLOSING- Present management was continued. Patient was closely monitored throughout
the hospital day.

MGH

Patient was seen and examined.

Vitals signs was monitored and recorded.

Diagnostics- Diagnostics done and noted (insert pertinent lab/diagnostic findings).

Subjective - Patient with no subjective complaints/ complaints of (symptoms)

Objective - Patient noted with no (signs/symptoms cough, fever, dizziness).

NEW ORDERS (If with new orders: DIET to MISCELLANEOUS)

(Usually: Medications discontinued.)
CLOSING- Patient was deemed fit for discharge. May go home.
OR Patient was deemed fit for discharge tomorrow. May go home.
Home medications and instructions were given to the patient, family/relatives. Patient was
discharged.

HAMA/THOC
Patient was seen and examined.

Vitals signs was monitored and recorded.

Patient was stable throughout the hospital day. Patient opted for HAMA/THOC, with HAMA/
THOC waiver. Risks and consequences were explained to the patient/relative, understood and
waiver signed. Patient was discharged.

DEATH
ACLS protocol started.

High quality CPR started.

Epinephrine started, given every 2 minutes. Pulse checked every 2 minutes.

Relative noted of prognosis of patient.

Noted time of death at 00:00.

Rendered post-morten care.