Off Service Note

This note is to let the oncoming physicians and residents know what is going on with the patient when you are leaving the service. Especially important if the patient has had a long hospital stay, ICU, etc.

ADMIT DATE:

ADMITTING DIAGNOSIS: list in order of importance.

HOSPITAL COURSE: Tells the story of the patient from when they were admitted until now, changes over time, lab studies, procedures, results.

PHYSICAL EXAM: brief, targeted.

PROBLEM LIST: list in order of importance.

ASSESSMENT: based on above data.

PLAN: medication changes, lab tests, procedures, consults, etc.