Welcome to MD+Chart!

Embedded in this page is a range of approved templates that we utilize at VJH. The aim is to improve efficiency in rounding and make decisions while providing exceptional care to our patients. We also aim to communicate with our multidisciplinary team to streamline decision pathways and facilitate safe discharges, while collecting important data, utilized by CIHI for Better Data. Better Decisions. Healthier Canadians.

Locums and contractees are encouraged to utilize these templates when working with us to ensure continuity of care for our patients. One of the key indicators we identified during the PQI journey was the value these had when it comes to complex discharges. 

How does it work?

The templates are in HTML format and is coded to be copied to your clipboard by clicking on the COPY button in the right upper corner of the template. Once you have clicked on the COPY button, right click within the pDoc software in Meditech and select paste. The template will be transferred and then you can start using the voice dictation software to dictate or type into the template.

CIHI (Canadian Institute for Health Information)

The Canadian Institute for Health Information (CIHI) provides comparable and actionable data and information that are used to accelerate improvements in health care, health system performance and population health across Canada. Our stakeholders use our broad range of health system databases, measurements and standards, together with our evidence-based reports and analyses, in their decision-making processes. We protect the privacy of Canadians by ensuring the confidentiality and integrity of the health care information we provide.

Learn More About CIHI

EDD

The EDD can now be added to the H&P or Consultation note within Meditech on admission and will remain in the Meditech Hospitalist Progress note when selected. This is an important key indicator and should be included at all times. 

Electronic handovers can be friend or foe, but in view of both departments utilizing electronic documentation, let’s see if we can use this simple template to do handovers via MBMD.

Name:
FP: 
Diagnosis:
Synopsis:
Urgency: See early/routine
Outstanding Investigations: 

HOSPITALIST ADMISSION NOTE
Vernon Jubilee Hospital


ID: []-year-old [] that lives in []. Family Physician [].


Referred by: []


REASON FOR ADMISSION:
[]


HISTORY OF PRESENTING ILLNESS:
[]


GOALS OF CARE:
MOST [current MOST status and if it was reviewed with patient this visit. Additional information etc. legal substitute decision maker, palliative care, DNR]
Advanced Care Plan: [N/A]
Representation Agreement: [N/A]


PAST MEDICAL HISTORY:
[]


PAST SURGICAL HISTORY:
[]


ALLERGIES:
[]


HOME MEDICATIONS:
[]


SOCIAL HISTORY:
ADL: [Independent, Spouse Assists, Family Assists, Other and refers to finances, meal prep, self care, Grocery Shopping, Transportation]
Living Conditions: [With Spouse, With friend, Alone with support, On reserve, Homeless, Supportive Housing, Assisted Living, LTC]
Meals: []
Support: [IHA, Mental Health, Private Care, Family]
Services: [None, Adult Day Service, Home Health, Home Support, Palliative Care, LTC]
Family: []
Substances: []
Alcohol: []
Occupation: []
Drivers License: [yes, important for stroke patients]
Marital Status: []
Mobility: []
Home O2: [N/A]
Lifeline: [N/A]
Pain Management: [N/A]


IMMUNIZATIONS:
COVID: []
Influenza: []
DPT: []


FAMILY HISTORY:
[None relevant]


EXAMINATION:
Vitals: []


General: []
HEENT: []
Chest: []
CVS: []
Abdomen: []
Neurology: []
Musculo-skeletal: []


SPECIAL INVESTIGATIONS:
1. Labs:
2. Diagnostics:


IMPRESSION:
[Generate a problem statement that can be carried over to the progress note. This is a summary of the problems identified. Bring all of the above together for the next physician]


ASSESSMENT & PLAN:
[Numbered or unnumbered list with condition, comments and plan]


DISPOSITION:
Admit to VJH Hospitalist
VTE: []
Diet: []
MOST: [If you made any changes or had discussions, leave out if captured in above section]
Consults: [PT, OT, TL, SW etc]


ELOS: []


Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.


Dr []

HOSPITALIST ADMISSION NOTE
Vernon Jubilee Hospital


ID: []


Referred by: []


REASON FOR ADMISSION:
[]


HISTORY OF PRESENTING ILLNESS:
[]


GOALS OF CARE:
[]


PAST MEDICAL HISTORY:
[]


PAST SURGICAL HISTORY:
[]


ALLERGIES:
[]


HOME MEDICATIONS:
[]


SOCIAL HISTORY:
[]


IMMUNIZATIONS:
[Up to date]


FAMILY HISTORY:
[None relevant]


EXAMINATION:
Vitals: []


General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I - XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]


SPECIAL INVESTIGATIONS: 
[] 


ASSESSMENT & PLAN: 
[] 


DISPOSITION: 
Admit to VJH Hospitalist 
VTE: [] 
Diet: [] 
MOST: [If you made any changes or had discussions, leave out if captured in above section] 
Consults: [PT, OT, TL, SW etc] 
EDD: [] 


Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

HOSPITALIST CONSULTATION NOTE
Vernon Jubilee Hospital


REFERRED BY: Dr []


ID: This is a []-year-old [] and a patient of Dr [] that lives in [].


REASON FOR REFERRAL:
[Reason for referral]


HISTORY OF PRESENTING ILLNESS:
[Provide more information about complaint, focusing on symptoms and events leading up to admission. Also incorporate collateral information]


GOALS OF CARE:
1. MOST [current MOST status]


PAST MEDICAL HISTORY:
1. []
2. []


PAST SURGICAL HISTORY:
1. []
2. []


ALLERGIES:
[]


HOME MEDICATIONS:
1. []
2. []


SOCIAL HISTORY:
ADL: []
Living Conditions: []
Support: []
Family: []
Substances: []
Alcohol: []
Occupation: []
Drivers License: [yes]
Marital Status: []


IMMUNIZATIONS:
1. COVID: []


FAMILY HISTORY:
[None relevant]


EXAMINATION:
Vitals: []


General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I - XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]


SPECIAL INVESTIGATIONS:
1. [List all pertinent investigations and mention positive and negative findings for each]
2. []


IMPRESSION:
[Generate a problem statement that can be carried over to the progress note. This is a summary of the problems identified.]


ASSESSMENT & PLAN:
1. []


Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.


Dr []

HOSPITALIST PROGRESS NOTE 
Vernon Jubilee Hospital


[80-year-old female admitted with CHF.]


TODAY:
[Capture SOAP elements reflecting changes in patient's condition, reasons for change of treatment and outcome of treatment]


Plan: 
[List today's plan]


ACTIVE ISSUES:
[Problem list]


RESOLVED/STABLE ISSUES:
[List, consider date when resolved, essentially secondary problems]


CONSULTATIONS:
[Date, consultant and advice]


PROCEDURES:
[None]


COURSE IN HOSPITAL:
[]


PMH:
[]


BARRIERS/VTE/EDD:
Barriers: []
VTE: []
EDD: []

This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me. 

HOSPITALIST PROGRESS NOTE 
Vernon Jubilee Hospital


[80-year-old female admitted with CHF.]


TODAY:
[Capture SOAP elements reflecting changes in patient's condition, reasons for change of treatment and outcome of treatment]


Plan: 
[List today's plan]


ACTIVE ISSUES:
[Problem list]


PMH:
[]


BARRIERS:
[]


VTE:
[]


This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me. 

HOSPITALIST PROGRESS NOTE 
Vernon Jubilee Hospital


MOST []


[Summary]


TODAY:
[Capture SOAP elements reflecting changes in patient's condition, reasons for change of treatment and outcome of treatment]


Plan: 
[List today's plan]


ACTIVE ISSUES:
[Problem list]


This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me. 

HOSPITALIST PROGRESS NOTE 
Vernon Jubilee Hospital


[80-year-old female admitted with urosepsis]


Subjective:
[]


Objective: 
[]


Assessment:
[]


Plan:
[]


BARRIERS/VTE/EDD:
Barriers: []
VTE: []
EDD: []


This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me. 

HOSPITALIST HANDOVER
Vernon Jubilee Hospital


ID: []


PRIMARY DIAGNOSIS:
[]


SECONDARY DIAGNOSIS:
[new diagnosis made after admission]


CONSULTATIONS:
[Date of consult, Consultant name and speciality, advice]


PROCEDURES:
[Date and Procedure]


DIAGNOSTICS:
[Highlight investigative findings]


PAST MEDICAL HISTORY:
[Insert Updated List, this is a check point to facilitate a good handover]


CURRENT MEDICATIONS:
[Import list from Meditech]


MEDICATIONS CHANGED:
[None, also mention reason]


COURSE IN HOSPITAL TO DATE:
[Summary of hospitalization]


TODAY:
[SOAP Note]


ACTIVE ISSUES:
[]


RESOLVED/STABLE ISSUES:
[]


BARRIERS/VTE/EDD:
Barriers: []
VTE: []
EDD: []


This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.

HOSPITALIST DISCHARGE SUMMARY
Vernon Jubilee Hospital


MOST:[]


DATE OF ADMISSION: []
DATE OF DISCHARGE: []
DESTINATION: []


PRIMARY DIAGNOSIS:
[]


SECONDARY DIAGNOSIS:
[]


CONSULTATIONS:
[]


PROCEDURES:
[None]


PAST MEDICAL HISTORY:
[Import from progress note and ensure updated with new findings]


DISCHARGE MEDICATIONS:
[]


SUMMARY OF ADMISSION:
[Provide a one paragraph summary, can import summary and just add information]


FOLLOW UP AND RECOMMENDATIONS: 
1. [Recommended follow up labs, imaging etc ]
2. [Results pending at time of discharge] 
3. [Referrals submitted while in hospital ]


Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.

NOTE PEARLS

1. Start your own note on D1 of your run and use the information provided to make a progress note that fits into your framework and way of thinking, while ensuring information does not get lost. This is particularly important for patients with prolonged stay in hospital.

2. Keep a running summary. The hardest part is probably to start figuring out what happened to the patient during the last 14 days.

3. Clearly communicate with the multidisciplinary team in the ELOS/Barriers/Disposition section. Based on feedback from multiple stakeholders (PCC, TL, OT, PT, Dietician, Pharmacy), this was deemed an important section when creating discharge plans for patients.

Due to the rise in complexity of patients under the hospitalist service since 2021, Internal Medicine have decided to start a ERCOM (Early Referral CO-Management) strategy for the patient under the hospitalist and Family Medicine services at VJH. All patients presenting with the following conditions will automatically be referred from the ER and the hospitalist service for IM input.

Why this shift?

Since the pandemic, the hospitalist service has experienced a significant influx of complex patients that requires specialist input. The IM department will be changing their rounding and consultation model to ensure that patients are seen early and co-managed with the hospitalist service and family medicine service. The goals are to reduce LOS, facilitate complete and timely work-up and to ensure good community follow-up post discharge. Evidence also shows that co-management will lead to better outcomes for patients, specifically those with complex medical problems.

This service will start on 21 March 2022 and IM will start with Cardiopulmonary first.

1. Cardiology;
   1. Acute coronary syndromes
   2. CHF
      1. All new CHF
      2. CHF exacerbations
   3. Syncope
   4. Atrial fibrillation/flutter;
      1. All new episodes
      2. Decompensated with rapid HR or CHF
   5. Ventricular tachycardia/wide complex tachycardia
   6. Moderate to Severe valvular disease
   7. Hypertensive emergency/urgency
   8. Aortic dissection
   9. Pericardial disease
      1. Pericarditis
      2. Pericardial effusion
2. Respirology;
   1. ILD
      1. All new cases
      2. ILD exacerbations
   2. Pulmonary hypertension
   3. Pulmonary embolism
      1. All new cases
   4. All patients needing BiPAP
   5. Hemoptysis
3. Gastroenterology;
   1. High risk GI bleeds
      1. Low BP, on anticoagulants, cardiac history….
   2. New cirrhosis (in concert with Brian)
   3. Acute liver injury (in concert with Brian)
4. Hematology;
   1. Pancyotopenia
   2. Thrombocytopenia <75
   3. DVT/PE
   4. Febrile neutropenia
5. Nephrology;
   1. AKI serum creatinine >300
   2. Hyponatremia with Na <120
6. Infectious disease
   1. Fever unknown origin
   2. Endocarditis
   3. Febrile neutropenia
   4. Bacteremia/fungemia
   5. Meningitis
   6. COVID needing >70% optiflow
7. Rheumatology;
   1. Vasculitis
      1. All new
      2. Flare of existing disease
8. Endocrinology;
   1. Adrenal disease
   2. Addisons
   3. Cushings
   4. Thyroid disorders
   5. New hyperthyroid
   6. New hypothyroid
   7. Hypercalcemia >2.75

NP HISTORY AND PHYSICAL
Vernon Jubilee Hospital
 
ID: []
 
SYNOPSIS:
[Provide summary of current admission and include subjective assessment as a separate paragraph of what it is happening that day]
 
REVIEW OF SYMPTOMS:
Neuro:  []
HEENT:  []
CVS:  []
Resp:  []
GI/GU:  []
MSK:  []
Sleep:  []
Bowel Movements:  []
Code Whites: []
 
PAST MEDICAL HISTORY:
[Make sure list is complete and new diagnosis are added]
 
SOCIAL HISTORY:
[Highlight the issues that is impacting discharge or relevant]
 
CURRENT MEDICATIONS:
[Import Macro from Meditech]
 
ALLERGIES:
[Consider importing from Meditech if allergies are relevant]
 
EXAMINATION:
Vitals:  []
 
[Patient was examined on 3E. He appears comfortable. He is not pale or jaundiced. He does not have significant edema. etc]
 
SPECIAL INVESTIGATIONS:
[Mention only relevant diagnostic tests, no need to give everything again. Highlight the abnormals during the admission]
 
IMPRESSION:
[Provide a high level overview of the current issue for example: This is a 96-year-old male with significant comorbidities including advanced dementia that needs a higher level of care.]
 
PROBLEM LIST:
[Here you can list active issues and your plan for each issue. Create it in such a manner that the hospitalist can follow and chase results that you feel needs to be reviewed. Also list your barriers and your plan for overcoming them.]
 
HOUSEKEEPING:
VTE: []
Diet: []
Catheter: [N/A]
Goals of Care: [Mention MOST status and that it was confirmed with substitute decision maker etc]
 
EDD:
[]
 
Thank you for involving the NP Service.
 
Stephanie Gyra, NP (F)

HOSPITALIST NP PROGRESS NOTE
Vernon Jubilee Hospital
 
MOST: []
 
SUMMARY:
[Create a summary that you can essentially use as the first paragraph of your discharge summary. Update it frequently. Also try and keep it succinct. Too much information is difficult to follow.]
 
TODAY:
[This your SOAP box where you can highlight the things that happened that day]
 
Plan:
[]
 
PROBLEM LIST:
[insert problem list, moved resolved issues into your summary]
 
DISPOSITION/ BARRIERS:
[What is keeping this patient in hospital]
 
EDD:
[Realistic discharge date and update daily after discussion with multidisciplinary care team]
 
This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
 
Stephanie Gyra, NP (F)

HOSPITALIST NP DISCHARGE SUMMARY
Vernon Jubilee Hospital
 
ID: []
 
DATE OF ADMISSION: []
DATE OF DISCHARGE: []
 
MOST: []
 
PRIMARY DIAGNOSIS:
[What is the main reason for the admission]
 
SECONDARY DIAGNOSIS:
[What is the other diagnosis while in the hospital]
 
CONSULTATIONS:
[Who was consulted during the admission]
 
PROCEDURES:
[]
 
PAST MEDICAL HISTORY:
[Create an updated list with new problems found]
 
DISCHARGE MEDICATIONS:
[You can simply import this from Meditech. Remove medications that is not going with the patient]
 
SUMMARY OF ADMISSION:
[Provide a summary of the admission mentioning relevant special investigations and course/complications]
 
FOLLOW-UP INSTRUCTIONS:
1. []
 
Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.
 
Stephanie Gyra, NP (F)

From: [Dr. Your name]
Location: [Vernon Emerge]



Date and Time of Symptom Onset: [date and time]
Date and Time of Referral to Clinic: [date and time]



Reason for Referral:
[State diagnosis]




Quick Summary Of Symptoms:
[]

Past Medical History:

[]
Medications:
[]



ABCD2 Stroke Score for TIA Patients


AGE:
Equal to or > 60 years (1)



BLOOD PRESSURE:
SBP > 140 or DBP > 90 (1)



CLINICAL FEATURES:
Unilateral weakness (2)
Speech disturbance without weakness (1)
Other Symptoms (0)



DURATION OF SYMPTOMS:
60 minutes or more (2)
10 - 59 minutes (1)
< 10 minutes (0)



DIABETES:
Yes (1)
No (0)



SCORE: [Enter Score]/7



Risk of Stroke within 2 days of TIA according to ABCD2 is:
6-7 then risk is 8.1%
4-5 then risk is 4.1%
0-3 then risk is 1%



[Information for referring physicians:
1. This is an outpatient unit. All patients must be appropriate for discharge home from the clinic. Patient must be independent and ambulatory.
2. Patients are not to drive themselves.
3. Do not send patient by ambulance.
4. Patients are responsible for their own meals and regular medications while being assessed.
5. Patients are to bring with them all their current medications.
6. Patient will receive diagnostic imaging for their Cerebral vascular symptoms, and neurology consultation to identify:
- Carotid stenosis, requiring endarterectomy
- Atrial Fibrillation or cardioembolic disease requiring warfarin or DOAC
- Small vessel disease requiring medical management
- Other stroke syndrome
- Non-stroke symptoms
7. For any patient requiring immediate assessment, please contact the neurologist on-call]