1. Documentation in your 3rd year and beyond
Summer Quarter 2011
Amanda Kocoloski and Whitney Crye

2. Overview General principles of documentation
Types of Notes, the case of Sarah Bell
Admit Note
Pre-Op Note
Procedure Note
Operative Report
Post-Op Note
Progress Note
Discharge Summary
L&D Admit Note
Labor Note
Medication Prescriptions
Assignment: Admission Orders

3. Introduction to hospital charting
Everything must be recorded somewhere!!!
When starting a new rotation become familiar with the chart ASAP
Paper vs. EMR
Always: Date, time, and sign with rank
Ask for templates or shortcuts; often designed to make things easier
When you get to a new rotation ask to see the chart and logistics of how the office works and where they want you to write

4. Sample patient: Sarah Bell
Sarah is a 35 y/o f presenting to your office (outpatient) with a bulge in her groin.
What do you want to know?
Which aspects of the exam will you perform?
What is your assessment?
What is your plan?

5. Outpatient Note
S: Pt is a 35 yo f presenting with a “bulge” in her groin x 2 months. It used to go away when she lays down but recently it remains even when supine. She admits to some discomfort and within the last day little abdominal pain that comes and goes. Last bowel movement 2 days ago. No nausea or vomiting.
O: VS: T: 99.1 BP: 120/65 P: 90 R: 14 pain: 4/10
CV: S1 S2 no murmurs, no gallops
Lungs: clear bilaterally, no wheezes, rhonchi, rales
Abdomen: soft, irreducible mass in right groin below inguinal ligament appreciated, no erythema, mild pain with palpation. Flat, bowel sounds present, no rebound, no guarding,
GU: no labial masses
LE: warm no skin discoloration, +2/4 patellar and Achilles DTRs bilaterally, pulses palpable,
A/P: 35 yo f with femoral hernia. Plan:1. admit to hospital 2. consult surgery

6. Sarah goes to the hospital
Sarah presents to the ER after her doctor calls ahead. You are sent to admit her to the floor.
What do you need to know?
What kind of exam will you do?
What is your assessment?
What is your plan?

7. Admission Note/History & Physical
CC: Pt is a 35 yo f presenting with a “bulge” in her groin
HxCC: duration 2 months. It used to go away when she laid down but recently it remains even when supine. She admits to some discomfort and within the last day a little sharp abdominal pain that comes and goes. Dull pain in groin 4/10. Last bowel movement 2 days ago. Motrin seems to help with the pain, coughing makes it worse. No nausea or vomiting. Ibuprofen was given in the ER which helped.
PMH: HTN
PSH: none
Meds: HCTZ
Allergies: NKDA
SHx: non-smoker, no alcohol, no illicit drug use; LPN by profession, married, 2 children
FHx: Mom alive, HTN; Dad deceased at 46 of MI with hx of HTN
ROS:
General:
Skin:
HEENT:
Chest:
Abdomen:
GU:
Extremities:
Neurologic:
Hematologic:
Psychiatric:
Endocrine:
PE: VS
Skin
CV:
Lungs:
GI:
Extremity:
Labs/Imaging: pelvic CT showed a femoral hernia of the right groin. No labs ordered as this time.
Assessment:
1. Femoral hernia.
2. HTN- controlled
Plan
Admission Orders
Admission orders to be discussed at the end of lecture and will include labs necessary to note in pre-op report

8. Sarah Preps for the OR
Sarah is admitted. She is scheduled to have surgery the next day.
What lab values do you need?
What else needs to be documented before surgery?

9. Surgery Pre-Op Note Pre-op Dx: femoral hernia
Procedure planned: Lotheissen-McVay femoral hernia repair
Labs: CBC, Chem 7, PT/PTT, UA
CXR: deferred
EKG: normal 3 months ago
Blood: type/screen, type/cross
Orders: 1.NPO 2. Antibiotics 3. skin prep
Permission: Informed consent signed/on chart
Anytime before procedure even just a few hours before.

10. Sarah in the OR
Sarah goes into the OR and has a simple herniotomy. Luckily the small bowel that is trapped in the hernia is still healthy. Mesh is placed at the hernia site.
What info should be documented?

11. Procedure/Op Notes
Procedure / Indication: Lotheissen McVay for femoral hernia
Permission
I explained the risk/benefits and alternatives to the patient. The patient voiced understanding. Consent form signed placed on chart.
Physician / Assistants: Dr. Lotheissen DO, A. Kocoloski MSIV
Estimated Blood Loss (EBL): 2mL
Description
Area prepped and draped in sterile fashion, Epidural anesthesia administered with Bupivicaine 0.5%. The abdominal wall was cut and the transversalis facia divided. The hernial sac was identified and small bowel was present in the canal. The bowel was healthy and removed from the hernial sac. Coopers ligament identified. Ethicon prolene mesh was placed over region. Sutures placed.
Complications: none
Disposition
Pt a/o, resting, breathing quietly, extremities neurovascularly intact. Incision clean, dry, intact. In stable condition.

12. Surgery Post-Op Note Pre-op diagnosis: femoral hernia
Post-op diagnosis: femoral hernia
Procedure: Lotheissen McVay femoral hernia repair
Surgeons: Dr. Lotheissen, A. Kocoloski MSIV
Findings: femoral hernia at right groin region with healthy bowel in the hernial canal
Fluids: 1000mL lactated ringers
Anesthesia: epidural
Estimated Blood Loss: 2 mL
Drains:none
Specimens: none
Complications: none
Condition/ Disposition: stable

13. Sarah recovers
Sarah is now post op and resting. You arrive at 5 am to do your pre-rounds.
What do you want to know?
What exam do you want to do?
How will your assessment be different?

14. Hospital progress Note
Brief note concerning past 24 hours
S: Pt did well overnight. Pain controlled with Vicodin. Passed gas, no bowel movement.
O: VS most recent; Exam: CV, Lungs, Abdomen, GU, Extremity; Incision: clean, dry and intact. Osteopathic: bogginess at right thigh, increased tissue tension of right gluteal muscles. Recent labs.
A/P: Pt is a 35 yo f pod#1 s/p right femoral hernia repair and right lower extremity somatic dysfunction. Will continue Vicodin for pain management. Advance diet and ambulation as tolerated. Continue to monitor I/O. Performed pedal pump and strain counter strain of both lower extremities, pt tolerated well.
Subjective: note brevity
Note POD terminology
Objective
Normal things in that section
Add things like gait, curves, presence of short let etc
Add TART findings
Add region findings including specific units ie. L5 FSR(L)
Assessment
SD in which regions
I.e. SD of lumbars, ribs, head, neck etc…
Specific findings (short leg, muscle spasm, disc herniations
Plan
OMT done by name and region; i.e. HVLA of cervicals

15. Discharge Note Admission/Discharge Dates: 7/2/11-7/5/11
Admission/Discharge Dx: Femoral hernia
Service: Surgery, Dr. Lotheissen
Referring Physician: Dr. Rhemy PCP
Consult: any physicians, service, dates
Procedures: date of surgery/procedure and type
Hx, PE: pertinent admission H&P and lab tests
Course: summary of treatment and progress
Discharge Condition: good, stable, fair, etc.
Medications: discharge meds, dose, refills
Instructions: restrictions, diet, care, symptoms to be aware of
Follow-up: appointment and emergency contact number

16. Practice!!! Progress Note So, who wants to send Mr. Sacamano home?
Mr. Robert Sacamano
So, who wants to send Mr. Sacamano home?
Anything he’ll need to complete treatment?
Start thoroughly, then work on speed
Only document what you do
Plan:
D/W intern/resident/attending
Can use previous note for completeness
Put thought into it, it helps set you apart

17. OB Progress Notes

18. L&D Admit Note
S: This ___year old female, wks, G P , EDD based on (dates or US at ___wks) presents to L&D for (labor ctx, bleeding, induction, c-section, PROM). Document if the patient feels FM, ROM, feels ctx, bloody show. Last US? _______any complications during pregnancy. (High BP, HA, change of vision, N/V, change of mental status)
Blood type, Rubella, Group B strep
GYN Hx: age of menarche x interval btw periods x how long periods last (13x28x4); hx of STI, abnl pap
OB Hx: G_T_P_A_L_
List any complications with previous pregnancies/deliveries
PMH:
PSH:
Meds:
Allergies:
FMH: (congenital anomalies, blood problems, birth defects in both mom and dad)
SHx: is father involved, good support?
O: PE: includes-VS. HEENT, Neuro, Heart, Lungs, Abdomen (BS, Gravid, Fundal height), Ext
SVE: cm / effacement / stage
Toco:
FHT’s:
Assessment: ___ yo, G_P__, ___ weeks
Plan: Continue monitoring during induction with Pit at ____mu.

19. Labor Progress Note
S: Pt resting comfortably and notes increased frequency and strength of ctx.
O: BP P
Any new observations as to the patients states
FHT:
SVE___/___/____
Toco: q____min or irregular, doublets or triplets
Pit___mu
A/P: ___yo G__P__at ___wks
Continue labor and increasing Pit per protocol, anticipate SVD
SVE: sterile vaginal exam (dilation/effacement/height)

20. Delivery Note: Vaginal Delivery
Type: SVD
Procedure: vacuum-assisted, forceps, episiotomy, laceration repair
Attending/Assist:
Anesthesia: type and person
Findings: Time of delivery, viable infant m/f, in ___position. ____Nuchal Cord, infant weight, APGAR__&__. ___degree laceration repaired with____. __vessel cord and segment collected. Placenta delivered (spontaneous, manual) intact.
EBL:
Complications: If present, list (thick meconium, nuchal cord, shoulder dystocia)
Condition:

21. Delivery Note: C-Section
Pre-operative Diagnosis: 38 week pregnancy, G1P0
Post-operative Diagnosis: 38 wk, G1P1
Procedure: Primary C-section
Surgeon & Assistant: Dr. Will; Assist Student Dr
Anesthesia: (General, epidural, spinal, etc.)
Estimated Blood Loss: 500mL
Findings: Include position (especially if breech), gender of infant, weight, APGAR scores, normal uterus, tubes & ovaries or describe if other than normal
Complications: if any or “none”
Condition: e.g. patient tolerated procedure well, transferred to recovery room in stable condition

22. Post-Partum Note Labs: pre  post (note if pending) PPD#__ or POD#__
Subjective:
Condition of patient: Patient resting comfortably in bed
Pain: Pain well-controlled, PQRST
Lochia: minimal, moderate, or heavy (greater than or less than a period)
Breast or Bottle feeding
Tolerating diet & liquids well
Ambulating with or without assistance
SOB, CP, Flatus, BM, Urinating, LE pain or swelling
Ask about birth control options
Objective: VS
Rh & Rubella status
Heart:
Lungs:
Abdomen: Bowel sounds present, if c/s dressing dry or dressing removed and incision healing well. Note any JP drainage. Fundal height, consistency, distension, tender
Urine output: voiding without difficulty, is Foley in place, urine clear
Extremities: swelling, signs of DVT- size or color discrepancy, Homan’s sign
Labs: pre  post (note if pending)
Assessment/Plan:
1. 24 yo f, G1P1, PPD #1 s/p SVD 1st degree laceration, progressing well, pain well-controlled with Tylenol— encourage ambulation, prescribe birth control, consult lactation specialist to address patient’s concerns, stool softener

23. Admission Orders: ADCA VAN DIMLS
Admit to service of…
Diagnosis
Condition
Allergies
Vital Signs
Activity
Nursing
Diet
IV orders
Medications
Labs
Special
Responsibility varies; if you are asked to write (any) orders date and sign them before your preceptor does

24. Admit Attending Physicians Name Unit/Floor:
Medical
Surgery
Medical ICU
Surgical ICU
If the family physician is not the same as the attending, you can notify the family doctor as a courtesy.
Admit: Dr. Duerfedlt, Medical Floor Notify: Dr. D.O. of patients admission

25. Diagnosis
Diagnosis: Pneumonia Secondary Diagnoses: Hypertension, DM Type 2
List both the diagnosis that caused the patient to be admitted (primary) and any other diagnosis(es) that the patient currently carries

26. Condition General condition of patient at time of admission
Stable
Guarded
Critical
Code Status
Condition: Stable Code Status: Full Code

27. Allergies Allergies: Penicillin; anaphylaxis
Medication, food or environmental allergies
Be sure to state the reaction if known

28. Vitals
Vitals: q shift (every 8 hours) Notify H/O if BP<90/60, >160/110; Pulse >110 or <60; temp>101.5; UOP<35cc/h for>2hours; RR>30 *H/O = house officer
Frequency: How often do you want this patient’s vitals checked
Is the patient’s condition one which you may expect a change over a short period of time?
Parameters
When should the doctor be called

29. Activity Restrictions on patients activity
Bed rest
Bedside commode
Up Ad Lib
Bathroom privileges
Ambulation
Up in chair
Up with nurse assistance
Fall precautions
Seizure precautions
Isolation
Activity: Bathroom privileges, Fall Precautions

30. Nursing
Any special functions that the nurse must carry out and frequency if applicable
I/O’s
Oxygen (some docs put this other places too)
Pulse oximeter
Accu checks
Drain and/or catheter instructions
Incentive spirometry
Wound care
Stool guaiac
Nursing: O2 2L via NC titrated to maintain sats at or above 95% Continuous pulse oximetry Accuchecks AC and HS Incentive spirometry q 2 hrs while awake

31. Diet State any dietary restrictions Diet: 1800 ADA diet
NPO (nothing per oral)
Ice chips only
Clear fluid only
Soft
Full
Thickened liquids
2200 calorie ADA
Cardiac
Low sodium
Low residue
Regular diet
Diet: 1800 ADA diet

32. IV *This section is reserved for IV fluid administration, NOT for IV medications*
IV: 0.9 NS KVO
If ordering IV fluids, state
Type of fluid (Normal Saline, Lactated ringer etc)
Additives (KCL, MG)
Rate in ml/hr at which fluid should be run
Endpoint for infusion
Maintenance fluids
Rehydration
Heplock
KVO
None

33. Medication List medication specific to patients primary diagnosis
List other meds that patient is currently taking that you want continued throughout admission
List PRN medications (i.e. pain, fever)
Include dose, mode of administration
Can vary the dosage or the dosing interval, not both
Be sure to include insulin orders here for patients getting Accuchecks

34. Example: Medication Levaquin IV 650mg q day
Tylenol 500 mg PO q 4-6 hr prn HA or fever greater than 101
Ambien 10 mg hs prn insomnia
Sliding scale coverage of accuchecks using low-dose algorithm
Duo-neb treatments q2hr prn SOB or wheeze
Duo-neb tx q 6hours
Mucinex 600mg PO Q 6hrs
Lisinopril 10 mg PO Q day

35. Labs Blood culture: now
List labs to be done and state when labs should take place
Do you want the labs done now or in the morning?
Remember admission orders are in place until the attending physician takes over patient care and changes orders. Think of what labs the attending will want to see when he or she evaluates the patient.
Blood culture: now
Sputum culture: now
CBC, chem 7: in am

36. Special Are there any special orders Respiratory therapy to follow
Ancillary services
Radiology
Consults
Special preps
Respiratory therapy to follow

37. Admission Orders Admit to: Dr. D on med-surg floor Dx: pneumonia
Secondary Diagnoses: HTN, DM type 2
Condition: stable
Allergies: Penicillin- anaphylaxis.
Vitals: q shift (every 8 hours) If temp is greater than 100.5° call attending
Activity: Bathroom privileges, fall precautions
Nursing: O2 2L via NC titrated to maintain sats at or above 95%. Continuous pulse oximetry. Accuchecks AC and HS. Incentive spirometry q 2hrs while awake.

38. Admission Orders Medications Diet: 1800 ADA
Levaquin IV 650mg qd
Tylenol 500mg PO q 4-6 hr prn HA or fever greater than 101
Ambien 10 mg hs prn insomnia
Sliding scale coverage of accuchecks using low-dose algorithm
Duo-neb treatments q2hr prn SOB or wheeze
Duo-neb tx q 6hours
Mucinex 600mg PO Q 6hrs
Lisinopril 10 mg PO Q day
Diet: 1800 ADA
IV: 0.9 normal saline to KVO
Labs
Blood culture: now
Sputum culture: now
CBC, chem 7: in am
Special: Respiratory therapy to follow

39. Note-Writing Resources
Maxwell Quick Medical Reference
A must-have!! Only $7.95!!
Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook)’
250 Mistakes 3rd year medical students make
Clinician’s Pocket Reference (Scut Monkey)
Medfools also has some sample personal statements