ON TREATMENT VISIT FORMAT

Today's date is [TODAYS DATE]

This is Dr. [YOUR NAME] dictating an OTV on [PATIENT'S FULL NAME]. The patient's hospital number is [HOSPITAL NUMBER]

Current Radiation Doses & Fields are [RADIATION DOSES (cGy) & FIELDS (up to 2)]

(for residents and fellows only)
The Attending physician is [ATTENDING's NAME]

Narrative: (Current Patient Situation)

Plan: (Updated Therapeutic Plans)

(for residents/fellows only)
The patient was seen jointly by Dr. [RESIDENT'S NAME] and Dr. [ATTENDING'S NAME]

P r o C L I P S ®     

ProCLIP Notes

Handy notes for easy
P r o C L I P S  dictations.

University of Pennsylvania Format

For further information, see ProCLIPS
on the World-Wide-Web at


http://www.proclips.com/


Copyright (c) AOTR, Inc. 1998 - 2002. All rights reserved
NOTE SELECTION GUIDE

HISTORY AND PHYSICAL: These notes are unique to each patient and should only be dictated for brand new patients.
ADDENDUM TO HISTORY AND PHYSICAL: Used to add new or updated information to an existing HISTORY prior to the initiation of therapy. Can be printed along with the H&P or under separate cover.
ON TREATMENT VISIT: Used to dictate information about patients currently receiving treatment. May also be used for information on patients about to begin treatment or on break from therapy.
COMPLETION SUMMARY (END OF THERAPY): Used to summarize a completed course of therapy.
FOLLOWUP NOTE: Used to enter information on patients who have completed a course of therapy. Patients must have a recorded completion summary to use this note. Otherwise, a RECONSULTATION NOTE or an INTERIM NOTE should be utilized.
RECONSULTATION NOTE: Used for new or recurrent probleme on patients who have received therapy or were previously seen in consultation but did not have subsequent therapy for whatever reason.
INTERIM NOTES: Used for patients who have an existing HISTORY, are not receiving and have not received treatments, and are being followied in anticipation of possible future therapy. This note may also be used to add additional information on a patient who has a recorded HISTORY but was not treated, but an "ADDENDUM TO HISTORY" is probably a better choice.
STAFF NOTES (CORRESPONDENCE NOTES): Generally used by Attending physicians to document consent, summarize a case, or other patient encounters not necessarily of clinical relevance.
DEATH NOTES: These should be dictated as FOLLOWUP NOTES in the case of a patient who has been treated, or INTERIM NOTES in the case of a patient who has not been treated.
TELECOMMUNICATIONS: These should be dictated using a format appropriate to the time and circumstances of the communications. Most often, thery are dictated as FOLLOWUP notes indicating that it is a telecommunication in the first narrative line of the note.		 HISTORY and PHYSICAL FORMAT

This is Dr. [YOUR NAME] dictating an H&P on [PATIENT'S FULL NAME], today's date is [TODAYS DATE], the patient's hospital number is [HOSPITAL NUMBER]. The patients date of birth is [PATIENT's DOB].
(for residents and fellows only)
The Attending physician is [ATTENDING's NAME]
The patients address and phone is [ADDRESS, WORK & HOME PHONE]

(Primary diagnostic information - this is the diagnosis for which the patient has been referred)
The histology and location are [HISTOLOGY + LOCATION]. The diagnosis date is [EXACT DIAGNOSIS DATE]. The disease stage is
T Stage [T-STAGE], N Stage [N STAGE], M Stage [M STAGE]
Overall Stage is (I-IV...) [STAGE]

The secondary diagnosis is (only necessary for patients with previous or second diagnosis) [REPEAT ALL DIAGNOSTIC INFO FROM ABOVE]

Primary and other referring physicians are: [PRIME REFERRING MD - 1st & last NAME], [REFERRING MDs 2 - 5: 1st & last NAMES]
History: The patient is a [AGE] [RACE] [GENDER]
[DICTATE COMPLETE HISTORY along with PHYSICAL EXAM... IMPRESSION and PLAN]

Thank you, Dr. [PRIMARY REFERRING MD] for asking us to see this patient.

(for residents/fellows only)
The patient was seen jointly by Dr. [RESIDENT'S NAME] and Dr. [ATTENDING'S NAME].