Format for On Service Note

MEDICAL STUDENT FORMAT FOR ON SERVICE NOTEI. Introduction:When a new physician (or medical student) comes onto a service and assumes thecare of a patient already on the ward an "on service" note is written. This is especiallyimportant if no "off service" note is on the chart. The "on service" note consists of:A. Brief admission historyB. Current Medications (not the ones he came into the hospital on)C. Hospital course: Discuss each active problem including how the patient feelsnow.D. New complaints if anyE. Physical exam: (brief and directed)F. Pertinent lab and x-rayG. Impressions & Plan (list all active problems and indicate what issuesremain unresolved)H. Discharge planningI. List of references you readBefore writing the note the student must:A. Review the current chart including ordersB. Interview the patientC. Do a brief directed physical examD. Review pertinent x-rays, EKG's, etc.EXAMPLEDate: 12/15/00Time: 11:10 a.m.On Service Note:A. History: This 75 yo w/m retired teacher with CAD s/p CABG (1992) and type2 diabetes x 15 years was admitted 12/10/00 (6 days ago) with CHF and poorlycontrolled diabetes. Admitting WT = 187 lb.B. Current Hospital Medications:Furosemide 40 mg bid poKCl 20 mEq qdNPH insulin 30 u Q AM; 15 u Q PMASA 1 daily

C. Hospital Course:1. CHF: The patient was treated with IV furosemide x 4 days + then switchedto po furosemide yesterday. He has lost 15 lbs and this a.m. weighs 172lb which is his baseline. He reports that his SOB and his peripheral edemahave resolved. 12/14/00 echo reveals LVEF of 35%.2. Type 2 DM: On admission the patient complained of excess thirst andvisual blurring despite maximum doses of glypizide and metformin. RandomBS=320, AIC=11.8. He has been started on bid NPH insulin with dosesgradually increased to 30 u NPH Q AM + 15 u NPH Q PM. QIDglucometer readings for the past 2 days are between 130 mg - 170 mg.The patient feels much less thirsty and reports no hypoglycemic symptoms.3. New Problem: Left great toe pain: Patient awoke this AM with a hot,swollen, severely painful left great toe. He denies fever, chills, rash, footdrainage or other joint complaints. This has never happened before.D. Physical Exam: Brief and Directed1. Vital signs (including weight and pulse ox), chest, heart andabdomen should always be checked.2. In this patient a careful exam for:a. residua of CHF (neck veins, rales, S 3 , edema)b. evidence of diabetic complications (pulses, bruits, fundi,peripheral neuropathy)c. left footd. ears and other joints for tophi should also be performed and commentedon.E. Recent Lab and X-ray: e.g.12/12/00 uric acid = 7.012/14/00 CBC, WNL, CHEM 7 WNL except for BS of 165 mg/dl12/14/00 Repeat chest x-ray = resolution of CHFF. Problem ListList ALL problems you identified: those in history, physical exam and throughtesting. Place them in general order of priority. You may not need to develop aPLAN for all the problems but it is important to identify them so you may seewhich could potentially fit together.

G. SummaryThis is the most important part of your workup. Think it through verycarefully. . There must be a pertinent differential diagnosis whereappropriate, e.g.Example: 75 yo Male with CAD, s/p CABG DM who was admitted 6 days agowith exacerbation of CHF and poor DM control, both of which areimproving. The patient now has developed acute gout.H. Assessment / Active Problem List/PlanThis should include a list of active problems and their likely causes. Pleaseplace in order of relative importance and highlight issues that are relevant tothis hospitalization.Example1. CHF 2ndry to CAD - control good on current furosemide dose. Will addlisinopril 10 mg today for unloading watching BP, K+, BUN + Cr. Will planto gradually reduce furosemide if possible and gradually increase lisinoprilto 20 mg daily as an outpatient. Will consider adding spironolactone and abeta blocker after lisinopril dose is maximized.2. Type 2 DM: Now on insulin with good control.3. Acute gout: Uric acid 3 days ago = 7. Will treat with a brief course ofindomethacin. As this is a first episode and occurred in the context ofhospital related stress, will not institute any preventive Rx for now.4. Discharge planning: A family meeting with wife and daughter are scheduledtoday for education regarding the patient's insulin injections, signs ofhypoglycemia etc. Target discharge date is tomorrow with follow-up withlytes, BUN/Cr, glucose in 7 days.I. List of references you read to learn about your patient’s symptoms, diagnoses,diagnostic tests, and/or therapies.SignatureJuly 2012