b. Progress Notes by Physician. The physicians' notes are documented on SF
509 (see figure 1-9). They provide an analysis of the patient's clinical course and outline
the rationale for specific medical decisions. Physicians' notes begin with an admission
note, continue with notes during hospitalization, and conclude with a note on discharge or
death.
(1) The admission note should briefly record the clinical circumstances that
brought the patient to the hospital, summarize the proposed diagnostic workup, and
suggest the type of therapeutic management. For emergency patients admitted, SF 558
(Emergency Care and Treatment) may be used as the admission note and placed in the
ITR.
(2) For surgical patients, the admission note may serve as the preoperative
note. In addition to giving the information described in paragraph 1-13b(1), these notes
must justify the surgery and state the procedure proposed.
(3) The physician or nurse anesthetist's preanesthesia note is recorded on SF
509 or SF 517 (Anesthesia Form), as appropriate. It should explain the choice of
anesthesia for the proposed procedure. The postanesthesia note must be made after the
patient has left the recovery area and must record the presence or absence of
anesthesia-related complications.
(4) For the postoperative patient, progress notes should record the condition of
the surgical wound, any indication of infection, and the removal of sutures and drains. It
should also record examinations of chest and legs until the patient is ambulatory (walking)
and afebrile (without fever). It also should record the use of casts or splints, and any other
pertinent data.
MD0753
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