Presentation on theme: "Documentation in your 3rd year and beyond"— Presentation transcript:
1Documentation in your 3rd year and beyond Summer Quarter 2010Merrian Brooks and Amanda Kocoloski
2Overview General principles of documentation Types of Notes, the case of Ineda SurgeryAdmission Orders
3Introduction to hospital charting EVERYTHING must be written somewhere!!!H&P, progress notes, labs, ordersPaper vs. EMRExample chartsAsk for templates or shortcuts; often designed to make things easier
4Sample 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?
5Outpatient NoteS: 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: 4/10CV: S1 S2 no murmurs, no gallopsLungs: clear bilaterally, good excursion, good air movementAbdomen: flat, bowel sounds present, no rebound, no guarding, soft, irreducible mass in right groin below inguinal ligament appreciated, no erythema, no pain with palpationGU: no labial massesA/P: 35 yo f with femoral hernia. Plan:1. admit to hospital 2. consult surgery
6Ineda 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?
7Admission note Full H&P related to CC Add a sentence (or 3) about the ER courseWhile in the ER pt received 200mg of ibuprofen, and a pelvic CT scan that showed a femoral hernia of the right groin.AssessmentPt has an irreducible mass beneath inguinal ligament that is also evident on CT consistent with a femoral hernia.PlanAdmission ordersOther elements may include: informant and reliability, development/immunization (peds), problem list (complex pt)
8Ineda Preps for the ORIneda 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?
9Surgery Pre-Op Note Pre-op Dx: femoral hernia Procedure planned: Lotheissen-McVay femoral hernia repairLabs: CBC, Chem 7, PT/PTT, UACXR: deferredEKG: normal 3 months agoBlood: type/screen, type/crossOrders: 1.NPO 2. skin prepPermission: Informed consent signed/on chart,Anytime before procedure even just a few hours before.
10Ineda in the ORIneda 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?
11Procedure/Op NotesProcedure / Indication: Lotheissen McVay for femoral herniaPermissionI 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 MSIVEstimated Blood Loss (EBL): 2mLDescriptionArea 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: noneDispositionPt a/o, resting, breathing quietly, extremities neurovascularly intact. Incision clean, dry, intact. In stable condition.
12Surgery Post-Op Note Pre-op diagnosis: femoral hernia Post-op diagnosis: femoral herniaProcedure: Lotheissen McVay femoral hernia repairSurgeons: Dr. Lotheissen, A. Kocoloski MSIVFindings: femoral hernia at right groin region with healthy bowel in the hernial canalFluids: 1000mL lactated ringersAnesthesia: epiduralEstimated Blood Loss: 2 mLDrains:noneSpecimens: noneComplications: noneCondition/ Disposition: stable
13Ineda recoversIneda 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?
14Hospital progress Note Brief note concerning past 24 hoursS: 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 brevityNote POD terminologyObjectiveNormal things in that sectionAdd things like gait, curves, presence of short let etcAdd TART findingsAdd region findings including specific units ie. L5 FSR(L)AssessmentSD in which regionsI.e. SD of lumbars, ribs, head, neck etc…Specific findings (short leg, muscle spasm, disc herniationsPlanOMT done by name and region; i.e. HVLA of cervicals
15Practice!!! Group 1. Hospital Progress Note A Group 2. Procedure Note: m/watch?v=R2_0gOI8 uV0&feature=relatedGroup 3. Hospital Progress Note BStart thoroughly, then work on speedOnly document what you doPlan:D/W intern/resident/attendingCan use previous note for completenessPut thought into it, it helps set you apart
16Admission Orders: ADCA VAN DIMLS Admit to service of…DiagnosisConditionAllergiesVital SignsActivityNursingDietIV ordersMedicationsLabsSpecialResponsibility varies; if you are asked to write (any) orders date and sign them before your preceptor does
17Admit Attending Physicians Name Unit/Floor: MedicalSurgeryMedical ICUSurgical ICUIf 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
18DiagnosisDiagnosis: Pneumonia Secondary Diagnoses: Hypertension, DM Type 2List both the diagnosis that caused the patient to be admitted (primary) and any other diagnosis(es) that the patient currently carries
19Condition General condition of patient at time of admission StableGuardedCriticalCode StatusCondition: Stable Code Status: Full Code
20Allergies Allergies: Penicillin; anaphylaxis Medication, food or environmental allergiesBe sure to state the reaction if known
21VitalsVitals: 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 officerFrequency: How often do you want this patient’s vitals checkedIs the patient’s condition one which you may expect a change over a short period of time?ParametersWhen should the doctor be called
22Activity Restrictions on patients activity Bed restBedside commodeUp Ad LibBathroom privilegesAmbulationUp in chairUp with nurse assistanceFall precautionsSeizure precautionsIsolationActivity: Bathroom privileges, Fall Precautions
23NursingAny special functions that the nurse must carry out and frequency if applicableI/O’sOxygen (some docs put this other places too)Pulse oximeterAccu checksDrain and/or catheter instructionsIncentive spirometryWound careStool guaiacNursing: 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
24Diet State any dietary restrictions Diet: 1800 ADA diet NPO (nothing per oral)Ice chips onlyClear fluid onlySoftFullThickened liquids2200 calorie ADACardiacLow sodiumLow residueRegular dietDiet: 1800 ADA diet
25IV *This section is reserved for IV fluid administration, NOT for IV medications* IV: 0.9 NS KVOIf ordering IV fluids, stateType of fluid (Normal Saline, Lactated ringer etc)Additives (KCL, MG)Rate in ml/hr at which fluid should be runEndpoint for infusionMaintenance fluidsRehydrationHeplockKVONone
26Medication List medication specific to patients primary diagnosis List other meds that patient is currently taking that you want continued throughout admissionList PRN medications (i.e. pain, fever)Include dose, mode of administrationCan vary the dosage or the dosing interval, not bothBe sure to include insulin orders here for patients getting Accuchecks
27Example: Medication Levaquin IV 650mg q day Tylenol 500 mg PO q 4-6 hr prn HA or fever greater than 101Ambien 10 mg hs prn insomniaSliding scale coverage of accuchecks using low-dose algorithmDuo-neb treatments q2hr prn SOB or wheezeDuo-neb tx q 6hoursMucinex 600mg PO Q 6hrsLisinopril 10 mg PO Q day
28Labs Blood culture: now List labs to be done and state when labs should take placeDo 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: nowSputum culture: nowCBC, chem 7: in am
29Special Are there any special orders Respiratory therapy to follow Ancillary servicesRadiologyConsultsSpecial prepsRespiratory therapy to follow
30Admission Orders Admit to: Dr. D on med-surg floor Dx: pneumonia Secondary Diagnoses: HTN, DM type 2Condition: stableAllergies: Penicillin- anaphylaxis.Vitals: q shift (every 8 hours) If temp is greater than 102° call attendingActivity: Bathroom privileges, fall precautionsNursing: 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.
31Admission Order Medications Diet: 1800 ADA Levaquin IV 650mg qdTylenol 500mg PO q 4-6 hr prn HA or fever greater than 101Ambien 10 mg hs prn insomniaSliding scale coverage of accuchecks using low-dose algorithmDuo-neb treatments q2hr prn SOB or wheezeDuo-neb tx q 6hoursMucinex 600mg PO Q 6hrsLisinopril 10 mg PO Q dayDiet: 1800 ADAIV: 0.9 normal saline to KVOLabsBlood culture: nowSputum culture: nowCBC, chem 7: in amSpecial: Respiratory therapy to follow
32Note-Writing Resources Maxwell Quick Medical ReferenceA must-have!! Only $7.95!!DO or MDPocket is an alternative but is $25.00How to be a truly EXCELLENT Junior Medical Student250 Mistakes 3rd year medical students makeClinician’s Pocket Reference (Scut Monkey)Medfools also has some sample personal statements