Medical Specialty:
SOAP / Chart / Progress Notes

Sample Name: Multiple Progress Notes


Description: Multiple Progress Notes for different dates in a patient with respiratory failure, on ventilator.
(Medical Transcription Sample Report)


PROGRESS NOTES

4/16/01:
Patient in respiratory failure, on ventilator
Request airline placement
Airline tracing good

4/17/01:
S: Sedated, intubated in NAD
O: Lungs: Increased bibasilar crackles
A/P: Respiratory arrest, pneumonia, COPD exacerbation
Replete K+, continue IVABX, start TPN, decrease TV, review ABGs

4/18/01:
S: Sedated and intubated, one episode NSVT
O: ABGs: 7.38/67/86/97

4/19/01:
S: Sedated and intubated, scant blood material from NGT
A/P: 1) Respiratory arrest
2) Exacerbation COPD - gastro cath NG aspiration

4/20/01:
S: Intubated/sedated, w/ NAD
O: Pulmonary - Increase L. basilar inspiration
A/P: Pneumonia
Respiratory arrest
COPD exacerbation
New onset low grade fever
D/C NGT - suspect sensitivity

4/20/01:
O: Preliminary blood culture gram + cocci
Dr. A called w/ result, no orders left
Pt. afebrile, WBC increase to 20.2
ABGs improved from 4/20/01, pt. noted to have less secretions
Last night had 8 beat run V-Tach

4/21/01:
O: Chest x-rays reviewed - improvement in lower lobe infiltrate
Gram + cocci in blood
Sputum H. influen. gram neg.

4/22/01:
atient up in chair
Decrease ventilator support
Preliminary blood cultures - Staph coag neg 1 of 2

04/23/01:
S: Awake, alert in NAD
O: Temp 99.8
Blood cultures: Staph coag. Neg. 1 of 2
A/P: Pneumonia, respiratory arrest, COPD
Continue wearing tirals

4/24/01:
S: Awake and alert, +N, refused trach
If fails extubation, will allow for reintubation
O: Temp. 99.4
ABGs: 7.9/52/70/94%
A/P: Pneumonia, respiratory arrest, COPD
Continue wearing tirals

4/24/01:
O: Patient off ventilator since this am

4/25/01:
S: Feeling well, no complaints
O: Temp. 99.4
A/P: Doing well s/p extubation
Change meds to po, advance diet

4/26:
S: Doing better, ambulating as same as yesterday
O: Temp. 97.9
A/P: Doing well, discontinue Foley
Plan to discharge home soon

4/2701:
O: Temp 97.8
A: Pneumonia, COPD

04/28/01:
Recurrent acute exacerbation of COPD

04/29/01:
O: Chest clear
Doing well

04/30/01:
S: Feeling better
O: Temp. 97.2
A/P: 4 + WBCs, sputum mod. gram neg. cocci, neg. blood infiltrates
Endstage COPD
D/C home


Keywords: soap / chart / progress notes, multiple progress notes, respiratory failure, ventilator, intubated, bibasilar crackles, pneumonia, copd, exacerbation, sedated and intubated, gram + cocci, gram +, gram neg, blood cultures, staph coag, progress notes, respiratory arrest, abgs, respiratory,