THE OFF-SERVICE NOTE

The continuity of care for patients is dependent on clear communication, both verbal and written.  Although you routinely discuss your patients with your resident, it is imperative that a thorough note reflecting all significant hospital events for your patient be left in the hospital chart the day you leave the service.  The off-service note is an extended version of the daily progress note.  The format is outlined below:

Subjective:  Rather than the usual brief reporting of patient’s complaints, you will report a summary of the HPI and all relevant hospital events to the date of the note, i.e. relevant test results, radiographic studies, antibiotic courses or other therapeutic interventions.
You should NOT transcribe the chart.  You will need to editorialize.  In most cases this section should not be more than a page!

Objective:  This section is expanded from the daily SOAP note format.
1) You will report the full physical exam for that day.  Please document the neurologic  
exam and the mental status.  You do not need to do a full MMSE.
2)  You will also report all pertinent serologic, radiographic and diagnostic studies. 
3)  You must report an accurate medication list for the patient.  The doses and start  
dates should be documented when possible, i.e. vancomycin 1 gm IV q12h started
11/20/03 or fosinopril 10 mg qd started 11/19/03.  This will aid in the appropriate
 discontinuation and titration of medications.

Assessment:  Here, you should completely, yet succinctly, summarize the current assessment of the patient.  

Plan:  You should completely review, by systems, the plan.  First, list the pertinent diagnoses followed by the plan, both diagnostic and therapeutic, for each entity.
For example:
 1) CV- ischemic cardiomyopathy s/p MI with EF of 25%; CHF; afib.  Continue to titrate carvedilol to highest dose tolerated; continue fosinopril, ASA, simvastatin.  Will reduce IV diuretics to furosemide 40mg IV qD from q12h .  Pt is out 2 liters in 24 hrs and crackles now minimal at the left base.  Pt still with irregularly irregular rhythm on telemetry with controlled rate in the 70s.

Continue this sort of review for each system.  Please be sure to include GI and DVT prophylaxis, if indicated, as well as nutrition and disposition.  Be sure to clearly state DNR status, if it is known or has been discussed.

Finally, please write legibly so that these important notes can be easily read!