Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Attending Physician:
Date of Note:
Reason for Encounter
Briefly state the reason for this encounter. This could be:
Suspected acetaminophen overdose (intentional or unintentional)
Follow-up visit for a patient with a history of acetaminophen overdose
History of Present Illness (HPI)
Ingestion:
Document the details of the acetaminophen ingestion, including:
Estimated time of ingestion (if known)
Amount of acetaminophen ingested (if known) – specify the product name, dosage, and number of units ingested if possible.
Circumstances surrounding the ingestion (intentional or unintentional)
Symptoms:
Describe any symptoms present since ingestion, including:
Nausea
Vomiting
Abdominal pain
Loss of appetite
Lethargy
Dark urine (later sign)
Past Medical History (PMHx):
Briefly mention any relevant past medical history, such as:
Liver disease
Alcohol abuse
Other conditions that may increase the risk of liver toxicity (e.g., malnutrition, genetic factors)
Medications:
List all current medications the patient is taking, including over-the-counter medications.
This is important to identify potential interactions with acetaminophen metabolism.
Social History (SHx):
Include relevant social history that may be pertinent, such as:
Alcohol use
Suicidal ideation (if applicable)
Physical Examination
General: Assess overall health, appearance of distress, and level of consciousness.
Vital Signs: Document blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Abdomen:
Assess for tenderness or pain.
Neurological: Briefly document mental status (alertness, orientation).
Assessment
Summarize the key findings from the history and physical examination.
Estimate the potential risk of hepatotoxicity (liver damage) based on the timing and amount of acetaminophen ingestion using a specific nomogram (e.g., Rumack-Matthew nomogram).
State the current assessment of the acetaminophen overdose (e.g., low risk, moderate risk, high risk).
Plan
Outline the next steps in the patient’s management. This may include:
Laboratory Tests:
Measure serum acetaminophen level (drawn at least 4 hours postingestion for accurate assessment).
Other tests may be indicated depending on the risk assessment, such as:
Liver function tests (LFTs)
Coagulation studies
Blood sugar
Electrolytes
Treatment:
The specific treatment depends on the timing of ingestion, the estimated risk of hepatotoxicity, and the presence of symptoms.
Options may include:
N-acetylcysteine (NAC) antidote – most effective if started within 8 hours of ingestion
Intravenous fluids
Supportive care
Consultation:
Consider consultation with a poison control center or gastroenterologist for complex cases.
Disposition:
The decision to admit or discharge the patient depends on the risk assessment, response to treatment, and presence of ongoing symptoms.
Patients at high risk of hepatotoxicity or with significant symptoms will likely require hospitalization for monitoring and treatment with NAC.
Patient Education:
Educate the patient and/or caregiver about the dangers of acetaminophen overdose and the importance of following dosage instructions carefully.
Provide information on safe medication storage and disposal.
If applicable, address any underlying mental health concerns that may have contributed to the overdose.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, ongoing management, follow-up visit).
Use clear and concise language while maintaining medical accuracy.
Document the time the acetaminophen level was drawn and the results when available.
Document any discussions or shared decision-making with the patient regarding the plan.
This template provides a framework for documenting progress notes for patients with acetaminophen overdose. Remember to tailor it to your specific workflow and facility’s documentation standards.