Reuben Notes

Admission H&P


CC: One sentence of the patient's cc

HPI: NLDOCAT (This is a __y.o. ___ Caucasian /AA M/F with PMH of _______ presented with c/o _______ in R/L foot/leg (specify the location) with ______(kind of pain) which started ______d/hr ago secondary to ______. Aggravating factor, course of cc, treatment rendered so far). Hx/mechanism of trauma if trauma case. Previous physicians seen.







Immunization hx

Last CXR, pop smear, PPD, EKG

ROS: HEENT, CV, Resp, GU, GI, M/S, dermatological, neuro, vasc,

DNR status:

Vitals: Temp, HR, RR, BP, orthostatic, O2 sat.

PE: general appearance, head, nose/ear, neck, CV, chest, abd, peripheral vasc, neuro, skin, rectal, genital, extremities, cranial nerves, M/S, cerebellar, gait, Radiographic exam, labs

Impression: All the medical conditions including non-podiatric

Plan: for each impression (consultation, followed by medicine, followed by podiatry, sx plan, d/c plan). Include: Casting, injection, DSG, Xrays, Rx (including dosage), ABX administered, WB status, nails/HK lesions debrided, labs/micro ordered, close reduction, debridement of the wound, irrigation, primary closure


D/W Drs._____ and _____ (medicine co-admitting attending and podiatry attending)

Sign/print last name/pager #

Daily SOAP note

Date/Time/Hospital day #/Postoperative day #/List of ABX the patient is on and each day # (in the margin)


Subjective - The patient is seen at bedside doing well/resting comfortably/feeling better/still c/o N/V/F/C/NS/CP/SOB/HA/D. Calf pain? Thigh pain? Appetite? Void? BM? List of complaints.


Objective -


Assesment - _________R/L foot/ankle/leg (specify the location) secondary to _______--stable/unstable/improving/good post-operative progress. And list all the other conditions.


Plan - DSG change regimen, Xrays, Rx (including dosage), continue ABX?, WB status, Sx plan, D/C plan, labs/micro ordered, debridement of the wound, irrigation, F/U plan, issues d/w the patient such as prognosis and future plans, consultations. D/W Dr._____ and Pod team (and other services.)


Sign/print last name/pager #

Standard Consult

Date/Time/Attending Dr's name/Reason for consult


Subjective - This is a __y.o. ___M/F with PMH of _______ presented with c/o _______ in R/L foot/leg (specify the location) with ______(kind of pain) which started ______d/hr ago secondary to ______. Cover NLDOCAT. If trauma, hx/mechanism of trauma.If infection, list his/her constitutional symptoms.


Objective - Temp, Pulse, Resp. rate, BP


Assesment - _________R/L foot/ankle/leg (specify the location secondary to _______--stable/unstable.



Sign/print last name/pager

Standard Consult

  1. pt name
  2. MR#
  3. Attending physician
  4. Date of admit
  5. Date of discharge
  6. Age
  7. Admit Dx
  8. CC and HPI
  9. Physical findings (read off H & P)
  10. Lab values
  11. Hospital course including: consults, and sx procedures
  12. Condition at D/C, disposition
  13. Discharge meds
  14. Follow-up date
  15. Final Dx
  16. Copies to be sent to....


Important note inclusions: