Page 1 -- this is the most important page
Name MEDICAL ACTION (full code, dnr, no cpr, whatever)
123 Main St
Anytown, ST 00000
Dad & Mom’s names
(list in descending order of importance)
(medication & strength) amnt & freq
Oxygen (yes, it’s a med) continuous
Sildenafil 2.5 mg/ml 2.5 ml q 6 hr
(same set-up as current meds but w/ dates and reason)
Septra 3.0 ml bid m/d-m/d/yy UTI
Ciprofloxin 100mg/ml .75 ml bid
1.5 ml bid
|Create text box w/ feeding info|
formula, feeding sched, &
24 hr total.
Page 2 (and so forth as needed to cover the history)
Current Physicians & Providers
(primary care first, then down in order of importance)
Best Doctor, MD pediatrician
357 S. Center St
Anytown, ST 00000
phone – contact name
Home Health Equipment
(include after hours emergency #)
Company name, phone
Oxygen (what they provide)
Company name, phone
Trach/Vent, O2 monitor, feeding supplies (what they provide)
Name of pharmacy
(list most recent first)
Procedures done, other pertinent info. Try to keep it short.
Dx: Tracheitis pseudomonas, eye infx
Rx: Cirpo 5g/100ml 1.5 ml bid for 10 days
Dx: Psuedomonas pneumonia
Rx: Cipro 100mg/ml 0.75 ml bid, Inc tidal volume 70, 1 ml air in cuffed trach
G-tube, Nissen, Tympanostomy, Bronchosope m/d/yy
50 tidal volume
0.3 sec/I time
13 pressure support
Alarm 45 high, 5 low pressure
Limited echo m/d normal cardiac function, PHT not measured
Discharge: Inc Previcid from 1.0 ml to 1.33 ml daily.
NJ tube placement – 44 cm nose to hub. 24 kcal breastmilk/formula. 456 ml@22ml/hr over 24 hours
Mm/dd-mm/dd/yyyy (in this case, since it’s NICU, from date of birth to discharge)
Dx: Trisomy 18
Mild pulmonary hypertension
Dysplastic tricuspid valve
Rx: Poly-vi-flor w/ iron .05 ml/daily
O2 ¼ l/min
(again list most recent first, record provider visits & telephone calls)
Date Dr. (full name) Notes(try to keep to 1-3 lines, very brief overview)
5/9/11 T/C cardio Inc sildenafil to 2.5 ml q 6 hr based on new weight.
5/6/11 Dr. K Weight check – 5.9kg; inc feeds to 720 ml/day, prevcid to 2ml
5/4/11 T/C Dr K HUGE desat (33%), order labs/x-ray @ Riverton. X-ray good,
most labs good, WBC 19,000. Rx cipro1.5 bid for 10 days.
5/2/11 N H, AUD ABR test shows almost no hearing, but responds to aud stimuli
with movement and inc heart rate. Refer to School for
Blind and Deaf for PIP EI.
3/29/11 Shriners Ortho consult. Splints for hands, 4-5 hr for thumb, sleeping for
resting splints. Spine okay. Club foot clinic in June
3/25/11 Dr. K 9 mo check up. Looks great! Last Hep B & Synergis shot
24 ½ inch, 12# 1oz, head circ 40.9cm, labs in 1 month
3/9/11 Trach/vent clinic Increase feeds. Keep 1ml air in cuff. Place trach when
inhaling. Check ear tubes during lip repair & do ABR. Lower brady setting to 60. 2nd flu shot. Rx: Tramcinolone acetnide bid prn for g-tube
Early Intervention or other Therapies
(use same format as dr visits)
4/1/11 OT Use ball for stretching. Lie down on lap for tummy time.
3/23/11 OT Work on standing muscles. Stretch hands. Sitting. Reaching
objects, swinging in a blanket.
2/8/11 Hearing test Referred both ears. Need ABR
10/8/10 OT Use yoga ball for strength training. Cellophane as
visual/auditory stimulation. Keep stretching hands
8/27/10 self decision Suspend use of bottle & oral feeds. Much fussier, gagging,
vomiting after feeds, mult desats. Wonder if, although he can protect his airways, if he gets “tired” & it’s too hard. Will try again starting next Tuesday.
8/31/10 self decision Discontinue bottle indefinitely after call to Dr. K.
(studies/labs done on an outpatient basis – same format as dr visit)
7/30/2010 PCMC Echo
8/17/2010 PCMC-Riverton Swallow study
9/8/2010 AFH Hearing screen DPOAE
*Use footer to date each time you update so you know how recent info is.
*Use abbreviations common to your area to save space – i.e. in Utah, everyone knows that PCMC is
Primary Children’s Medical Center and UVRMC is Utah Valley Regional Medical Center.
*Make changes you need to make this work for you. It is not a Bible. It is a work in progress.
I wish all of my families with chronically ill patients would create a list like this. I would add allergies to page one though.ReplyDelete
Oops, it doesn't copy and paste real well onto blogger, so I was kind of recreating it as I went. On my sheets, the ones clipped to his meds chart, it says in bold, right below the vent setttings box: No Known Medical Allergies and Immunizations Current (because they always are). I agree. a MUST for any EMS trying to treat a patient.ReplyDelete
We keep something similar for Lily. However, because her allergies are extreme, we list them above her diagnoses. Versed, a very common in-the-field sedative, causes Lily to code, her heart and breathing to stop completely. None of the rest of her allergies are THAT bad, but I agree with you and the above commenter... we have to share those allergies to protect our kids.ReplyDelete
oh wow this is very nice! Love it!ReplyDelete