• Admitted Patient Consultation Respiratory Distress
• Mid Level Chart Attestation
• Medical Student Chart Attestation

Admitted Patient Consultation Respiratory Distress

Consulted for emergent aid for this patient in respiratory distress.
Upon arrival to patient room it was clear that the patient was in fact in respiratory distress necessitating airway intervention.
Shared decision among teams was made to intubate the patient.
Patient was intubated successfully without complications and placed on the ventilator.

Procedure: Intubation
Indication: Respiratory Failure
Intubated with # 7.5 ETT curbed blade, oral
Patient was preoxygenated and premedicated as documented in the medication record.
Placement of ETT was confirmed by end-tidal CO2 detector and auscultation, and a CXR has been ordered.
Placement of ETT was not corrected.
Patient tolerated procedure well without complications.

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Mid Level Chart Attestation

Not Visualized or Discussed
I was available in the emergency department for questions or consultation however none was sought.
I was not involved in the care of this patient and am signing this chart for administrative purposes only.

Not Visualized, but Discussed
I was consulted for advice regarding this patient’s presentation and exam findings.
Given History and Exam, presentation most consistent with ***
I agree with their history, ROS, findings and plan as documented in their note in the patient’s medical record.

Visualized
I was consulted for advice regarding this patient’s presentation and exam findings. I saw and evaluated the patient, and discussed the case with the primary provider querying assistance.

Physical Exam
General: in NAD
Head: Normocephalic
Eyes: EOMI
ENMT: moist oral mucosa
Neck: trachea midline
Cardiovascular: peripheral perfusion normal
Respiratory: no respiratory distress
Abdomen: nondistended
Extremities: warm
Psych: Cooperative
Neuro: Alert

Medical Decision Making
Given History and Exam, presentation most consistent with ***
I agree with their history, ROS, findings and plan as documented in their note in the patient’s medical record.

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Medical Student Chart Attestation

I saw and evaluated the patient, and discussed the case with the medical student.
I agree with their findings and plan as documented in their note in the patient’s medical record.
Exam: ***
Given History and Exam, presentation most consistent with ***.
Disposition: Discharge. Discussed strict return precautions with patient.