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:
Initial evaluation for suspected ACS.
Follow-up visit for a patient with established ACS.
Monitoring response to treatment for ACS.
Post-operative management following intervention for ACS.
History of Present Illness (HPI)
Focus on symptoms suggestive of ACS, including:
Abdominal pain (onset, severity, character, location)
Abdominal distention
Nausea and vomiting
Difficulty breathing
Decreased urine output
Mention the duration, progression, and any aggravating or alleviating factors for the symptoms.
Past Medical History (PMHx)
Briefly mention any relevant past medical history that may have increased the risk of ACS, such as:
Abdominal surgery
Intra-abdominal sepsis
Pancreatitis
Major burns
Trauma
Social History (SHx)
Include relevant social history, such as:
Alcohol use
Smoking history
Medications
List all current medications the patient is taking.
Allergies
Document any known allergies, especially to medications.
Physical Examination
General: Assess overall health, appearance of distress, and signs of respiratory compromise.
Vital Signs: Document blood pressure, heart rate, respiratory rate, oxygen saturation, and temperature.
Abdomen:
Inspect for distention, discoloration, or paradoxical movement (movement with respiration).
Palpate for tenderness, guarding (involuntary muscle tensing), and assess for dullness to percussion (indicates fluid accumulation).
Measure abdominal girth and document changes since previous measurement (if available).
Rectal Examination: May reveal stool impaction contributing to ACS.
Laboratory Tests
Mention relevant laboratory tests obtained and their results, including:
Blood tests (complete blood count, electrolytes, blood gas)
Lactic acid levels (elevated levels suggestive of ACS)
Imaging Studies
Mention any imaging studies performed and their results, such as:
Abdominal X-ray
Abdominal ultrasound
CT scan of the abdomen and pelvis
Assessment
Summarize the key findings from the history, physical examination, labs, and imaging.
State whether ACS is confirmed, suspected, or ruled out.
If confirmed, estimate the severity of ACS based on intra-abdominal pressure (IAP) measurements (if available) and clinical criteria.
Plan
Outline the next steps in the patient’s management. This may include:
Initial Resuscitation:
Address fluid resuscitation, electrolyte imbalances, and hemodynamic support as needed.
Intra-abdominal Pressure (IAP) Monitoring: If not already initiated, mention the plan for IAP monitoring (e.g., bladder catheter with transducer).
Definitive Management: If ACS is confirmed, urgent surgical intervention to decompress the abdomen is typically necessary. Specify the planned surgical procedure (e.g., laparotomy, decompression fasciotomy).
Management of Underlying Cause: Address the underlying cause of ACS medically or surgically (e.g., antibiotics for sepsis, bowel resection for bowel perforation).
Vasopressors: If indicated to maintain blood pressure in the setting of aggressive fluid resuscitation.
Mechanical Ventilation: May be necessary for respiratory support if ventilation is compromised.
Serial Monitoring: Close monitoring of vital signs, urine output, and IAP is crucial.
Prognosis: Briefly discuss the prognosis which can be guarded depending on the severity of ACS and underlying condition.
Additional Considerations
Adapt this template based on the specific situation (initial evaluation, established ACS, post-operative management).
Use clear and concise language while maintaining medical accuracy.
Document the urgency of the situation if ACS is confirmed.
Document any discussions or shared decision-making with the patient regarding the plan, especially regarding risks and benefits of surgical intervention.
This template provides a framework for documenting progress notes for patients with suspected or confirmed ACS. Remember to tailor it to your specific workflow and facility’s documentation standards.