01 / ADAPTABLE OUTLINE
What to document
Overnight events & subjective update
Hospital day, major interval events, patient concerns, symptom changes, oral intake, mobility, nursing issues, and response to recent interventions.
Objective trends
Vitals and oxygen requirement, intake/output, weight when relevant, focused examination, pertinent laboratory trends, imaging, cultures, and pending results.
Problem-based assessment & plan
For each active problem: trajectory, supporting data, treatment changes, tests, consultant input, medication adjustments, and reassessment criteria.
Safety, handoff & disposition
Diet and activity, VTE and bleeding-risk assessment, lines or catheters, verified code status, reconciliation, discharge barriers, anticipated needs, and ownership of follow-up.
02 / WORKED EXAMPLE
Hospital day 2 — improving dehydration-associated acute kidney injury
Illustrative documentation only. Not patient data, a treatment protocol, or a complete billing checklist.
Interval events
A 69-year-old female is reviewed on hospital day 2 after admission for poor intake and acute kidney injury. No acute overnight event is reported. Nausea has resolved and the patient is tolerating breakfast. Nursing reports improved urine output. The patient still needs assistance walking to the bathroom.
Objective
Temperature 36.8°C, BP 118/70 mmHg, pulse 80, respiratory rate 16, SpO2 96% on room air. The patient is alert with clear lungs, a soft nontender abdomen, and no edema. Creatinine has improved from 1.8 to 1.3 mg/dL; documented baseline is 1.0 mg/dL. Potassium is 4.1 mmol/L.
Assessment & plan
1. Acute kidney injury in the setting of reduced intake: improving after volume repletion. Stop maintenance IV fluid now that intake and volume assessment support oral hydration. Continue intake/output monitoring and repeat renal studies tomorrow. Review nephrotoxic exposure and renal dosing; reassess previously held medicines individually rather than automatically restarting them. 2. Reduced mobility: assisted ambulation and therapy assessment today. 3. Inpatient safety: review VTE prevention against mobility, renal function, and bleeding risk; document the selected orders separately.
Disposition & handoff
Discharge remains pending stable oral intake, renal trend, and a safe mobility plan. Discuss anticipated needs with the patient, nursing, therapy, and case management. Complete discharge medication reconciliation and name the clinician responsible for repeat renal testing and follow-up before discharge. Do not describe discharge as completed while these decisions remain pending.
03 / SETTING-SPECIFIC CARE PLAN
Treatment, monitoring & coordination
Adapt the plan to the patient, care setting, and goals. These prompts do not create orders or imply that care was performed.
Daily treatment decisions
Identify which treatments continue, change, stop, or remain on hold and why. Record actual doses, routes, monitoring, and renal adjustments in the medication plan. Separate proposed actions from orders already placed.
Medication reconciliation at transitions
Compare the verified preadmission regimen with admission, transfer, and discharge orders. Resolve discrepancies and explain intentional changes so the next clinician and the patient understand the plan.
Discharge readiness
Document unresolved clinical and functional barriers, destination and support needs, pending tests with a named reviewer, return instructions, and follow-up arrangements. Include the patient and caregiver in the plan.
A common documentation question
Is this also a discharge summary?
No. This is a daily progress-note framework. A discharge summary separately describes the hospitalization, final diagnoses, reconciled medicines, disposition, instructions, pending results, and follow-up arrangements.