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emr:soap

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Assessment / Plan 65M with history of x, initially admitted for X, now with x.

Acute hypoxemic respiratory failure Septic shock from GNR bacteremia Acute kidney injury, grade 2

Recommendations - XX - xxx

Billing Details

Subjective - overnight, no acute events - reports no specific concerns

Full ROS performed. Negative except as mentioned above.

Objective Vitals Tmax x

Exam RRR.CTAB

Labs & Imaging

All labs and imaging within past 24 hr personally reviewed by me.

emr/soap.1698674834.txt.gz · Last modified: 2023/10/30 14:07 by admin