Hospitalist Progress Note Template

No events overnight. Weaned from 2 L/min nasal cannula to room air at 06:00. Admission blood cultures have no growth at 48 hours.

Feels “much better.” Cough still productive but looser; short of breath only when walking the hallway. Ate half of breakfast. Slept well. Walked the hallway twice with physical therapy. No chest pain or diarrhea.

T max 37.6 °C (99.7 °F); HR 82 to 96; BP 124 to 138/70 to 80; RR 16 to 20; SpO2 92 to 95% on room air since 06:00. Intake 1.6 L, urine 1.4 L. Weight 64 kg (141 lb), unchanged. Alert and comfortable at rest. Crackles at the right base, fewer than yesterday; no wheeze. Heart regular. No leg swelling. IV site clean.

White count 9.1, down from 14.8 on admission. Creatinine 1.1 mg/dL (97 µmol/L), back to baseline from 1.4 mg/dL (124 µmol/L). Sodium 137, potassium 4.0 mmol/L. Glucose 7.8 to 10.6 mmol/L (140 to 190 mg/dL). Sputum: normal respiratory flora. Blood cultures: no growth at 48 hours. Ceftriaxone 1 g IV daily, day 3; azithromycin 500 mg daily, day 3 of 3.

72-year-old woman with type 2 diabetes and hypertension, admitted with right lower lobe community-acquired pneumonia, hospital day 3, improving. 1. Pneumonia, improving: afebrile for 30 hours, off oxygen, eating. Switch ceftriaxone to amoxicillin-clavulanate 875/125 mg by mouth twice daily; azithromycin course complete today. Plan 5 days of antibiotics in total if she stays clinically stable. Walking oximetry before discharge. 2. Acute kidney injury, resolved with fluids: IV fluids stopped; encourage oral fluids. 3. Type 2 diabetes: correction insulin per protocol; metformin held, to restart at discharge with creatinine at baseline. 4. Hypertension: amlodipine continued; BP at goal.

VTE prophylaxis: enoxaparin 40 mg subcutaneously daily. Lines: peripheral IV, day 3, to come out after the switch to oral antibiotics. No urinary catheter. Diet: consistent carbohydrate. Activity: walk the hallway 3 times a day; physical therapy assesses her as safe for home. Code status: full code, confirmed with the patient on admission.

Expected discharge tomorrow, home with her husband, if she stays stable on oral antibiotics and her SpO2 stays at 90% or above while walking. Barrier: 24 hours on oral treatment. Follow-up with her family physician within 1 week. Patient and husband updated at the bedside.

No events overnight; no arrhythmias on telemetry. Pharmacist medication history: he missed his furosemide for 5 days before admission.

Breathing easier; slept on 2 pillows instead of 4. Still short of breath walking to the bathroom. Legs less swollen. Passing a lot of urine. No chest pain, dizziness, or palpitations.

T 36.6 °C (97.9 °F); HR 72 to 88, sinus rhythm; BP 104 to 118/62 to 74; RR 18 to 22; SpO2 93 to 95% on 1 L/min nasal cannula. Intake 1.1 L, urine 2.9 L, net balance negative 1.8 L. Weight 91.2 kg (201 lb), down from 92.4 kg (204 lb) yesterday; estimated dry weight 88 kg (194 lb). JVP 10 cm, down from 14 cm. Crackles at both bases, a third of the way up yesterday. Pitting edema 2+ to mid-shin, from 3+ to the knees. Heart regular, no new murmur.

Sodium 135 mmol/L; potassium 3.7 mmol/L, from 4.1. Creatinine 1.4 mg/dL (124 µmol/L), from 1.3 mg/dL (115 µmol/L); baseline 1.2 mg/dL (106 µmol/L). Magnesium 1.9 mg/dL (0.78 mmol/L). High-sensitivity troponin flat at 22 and 24 ng/L. NT-proBNP 4,850 pg/mL on admission. Last echo 8 months ago: ejection fraction 30%. Furosemide 40 mg IV twice daily, day 2.

68-year-old man with heart failure with reduced ejection fraction, admitted with decompensation after missed diuretic doses and a salty diet, hospital day 2, improving. 1. Acute on chronic heart failure, responding to diuresis: continue furosemide 40 mg IV twice daily, aiming for a net negative 1 to 2 L a day toward a dry weight of about 88 kg (194 lb). Daily weights, strict intake and output, electrolytes and creatinine daily. Carvedilol, sacubitril-valsartan, spironolactone, and dapagliflozin continued at home doses while BP allows. Wean oxygen to keep SpO2 at 92% or above. Switch to an oral diuretic when near dry weight. 2. Creatinine rise: small and expected with decongestion; recheck in the morning. 3. Hypokalemia: potassium chloride 20 mmol (20 mEq) by mouth today; aim for potassium 4.0 mmol/L or higher. 4. Missed doses: teaching from the pharmacist and the heart failure nurse; pill organizer.

VTE prophylaxis: enoxaparin 40 mg subcutaneously daily. Lines: one peripheral IV, day 2, needed for IV diuretics. No urinary catheter; urinal for output. Diet: low sodium. Activity: walking in the room and the hallway with nursing; physical therapy to assess. Code status: full code; he wants to talk about advance care planning with his wife before discharge.

Expected discharge in 2 to 3 days, home, once near dry weight and stable for 24 hours on an oral diuretic. Barriers: still volume overloaded; needs a scale at home. Heart failure clinic follow-up within 7 days of discharge to be booked. Wife updated by phone.