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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

  • Problems: 1,2,3
  • Data: xx
  • Risk: xx

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.1698677992.txt.gz · Last modified: 2023/10/30 14:59 by admin