외과일기 (12) Generic Progress Note

Posted by hi G on 2012. 6. 30. 02:05
-SUBJECTIVE
pt c/o fatigue but otherwise doing well

--OBJECTIVE
NAD, disoriented x 3
afebrile, vital signs stable
RRR, CTAB

--ASSESSMENT & PLAN 
25yo F s/p surgery shelf on POD#0 
-pain control with EtOH prn
-advnace to reg diet
-f/u DMT for weekend plans! woot woot