JFSAP

Assessment/Plan:

Hospital Problems:

1.

2.

3.

4.

5.

6.

Plan:

1. Neuro:

2. CV:

3. Pulmonary:

4. Renal/FEN:

5. GI:

6. Endocrine:

7. Heme:

8. ID:

9: Best Practices:

- DVT prophylaxis: ***

- GI prophylaxis: ***

- Glycemic control: ***

- LDA: ***

- Nutrition: ***

The patient is critically ill and requires high complexity decision making for assessment and support including: frequent evaluation and titration of therapies; extensive interpretation of multiple databases; application of advanced monitoring technologies and assessment and treatment of complex metabolic derangement.

Care during the described time interval was provided by me. I have reviewed this patient's available data, including medical history, events of note, physical examination and test results, and have overseen the activities of other members of the care team under my direct supervision (e.g. house officers, nurse practitioners). 

Critical care time, exclusive of procedures, was *** minutes.