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Documentation in your 3rd year and beyond
Summer Quarter 2010 Merrian Brooks and Amanda Kocoloski
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Overview General principles of documentation
Types of Notes, the case of Ineda Surgery Admission Orders
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Introduction to hospital charting
EVERYTHING must be written somewhere!!! H&P, progress notes, labs, orders Paper vs. EMR Example charts Ask for templates or shortcuts; often designed to make things easier
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Sample patient: Ineda Surgery
Ineda 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?
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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 denies discomfort. Last bowel movement yesterday. 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, good excursion, good air movement Abdomen: flat, bowel sounds present, no rebound, no guarding, soft, irreducible mass in right groin below inguinal ligament appreciated, no erythema, no pain with palpation GU: no labial masses A/P: 35 yo f with femoral hernia. Plan:1. admit to hospital 2. consult surgery
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Ineda goes to the hospital
Ineda 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?
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Admission note Full H&P related to CC
Add a sentence (or 3) about the ER course While in the ER pt received 200mg of ibuprofen, and a pelvic CT scan that showed a femoral hernia of the right groin. Assessment Pt has an irreducible mass beneath inguinal ligament that is also evident on CT consistent with a femoral hernia. Plan Admission orders Other elements may include: informant and reliability, development/immunization (peds), problem list (complex pt)
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Ineda Preps for the OR Ineda 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?
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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. skin prep Permission: Informed consent signed/on chart, Anytime before procedure even just a few hours before.
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Ineda in the OR Ineda 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?
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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.
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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
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Ineda recovers Ineda is now post op and resting. You arrive at 4 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?
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Hospital progress Note
Brief note concerning past 24 hours S: Pt did well overnight. Pain controlled with ibuprofen. Passed gas, no bowel movement. O: VS most recent; Exam: CV, Lungs, Abdomen, GU; 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 ibuprofen for pain management. Advance diet 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
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Practice!!! Group 1. Hospital Progress Note A
Group 2. Procedure Note: m/watch?v=R2_0gOI8 uV0&feature=related Group 3. Hospital Progress Note B 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
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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
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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
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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
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Condition General condition of patient at time of admission
Stable Guarded Critical Code Status Condition: Stable Code Status: Full Code
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Allergies Allergies: Penicillin; anaphylaxis
Medication, food or environmental allergies Be sure to state the reaction if known
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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
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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
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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
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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
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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
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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
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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
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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
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Special Are there any special orders Respiratory therapy to follow
Ancillary services Radiology Consults Special preps Respiratory therapy to follow
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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 102° 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.
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Admission Order 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
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Note-Writing Resources
Maxwell Quick Medical Reference A must-have!! Only $7.95!! DO or MDPocket is an alternative but is $25.00 How to be a truly EXCELLENT Junior Medical Student 250 Mistakes 3rd year medical students make Clinician’s Pocket Reference (Scut Monkey) Medfools also has some sample personal statements
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