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medical progress notes on nursing home residents
Recommended format is the 'SOAP' note.
Subjective:
1) new complaints
2) symptoms related to active medical conditions
Objective
1) general appearance
2) weight
3) vital signs
4) physical findings relevant to
a) new complaints
b) active medical conditions
5) reports from nursing staff
a) functional status
b) behavior
6) progress in rehabilitation (if relevant)
7) reports of other interdisciplinary team members
8) laboratory data
9) consultant reports
Assessment
1) presumptive diagnosis of new complaints or changes in status
2) stability of active medical conditions
3) response to interventions
a) psychotropic medications
b) rehabilitation
c) other
Plan
1) changes in medication or diet
2) nursing interventions
a) monitoring of vital signs
b) skin care
c) other
3) assessments by other services
a) rehabilitation therapists
b) consultants
4) laboratory studies
5) discharge planning (if relevant)
Related
annual physician review of long term nursing home residents
References
- Ouslander JG, Osterweil D.
Physician evaluation and management of nursing home residents.
Ann Intern Med 120:584, 1994
PMID: 8116998