Presentation on theme: "Documentation in your 3rd year and beyond"— Presentation transcript:
1Documentation in your 3rd year and beyond Summer Quarter 2011Amanda Kocoloski and Whitney Crye
2Overview General principles of documentation Types of Notes, the case of Sarah BellAdmit NotePre-Op NoteProcedure NoteOperative ReportPost-Op NoteProgress NoteDischarge SummaryL&D Admit NoteLabor NoteMedication PrescriptionsAssignment: Admission Orders
3Introduction to hospital charting Everything must be recorded somewhere!!!When starting a new rotation become familiar with the chart ASAPPaper vs. EMRAlways: Date, time, and sign with rankAsk for templates or shortcuts; often designed to make things easierWhen 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
4Sample 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?
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 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: 4/10CV: S1 S2 no murmurs, no gallopsLungs: clear bilaterally, no wheezes, rhonchi, ralesAbdomen: 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 massesLE: 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
6Sarah 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?
7Admission Note/History & Physical CC: Pt is a 35 yo f presenting with a “bulge” in her groinHxCC: 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: HTNPSH: noneMeds: HCTZAllergies: NKDASHx: non-smoker, no alcohol, no illicit drug use; LPN by profession, married, 2 childrenFHx: Mom alive, HTN; Dad deceased at 46 of MI with hx of HTNROS:General:Skin:HEENT:Chest:Abdomen:GU:Extremities:Neurologic:Hematologic:Psychiatric:Endocrine:PE:VSSkinCV: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- controlledPlanAdmission OrdersAdmission orders to be discussed at the end of lecture and will include labs necessary to note in pre-op report
8Sarah Preps for the ORSarah 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. Antibiotics 3. skin prepPermission: Informed consent signed/on chartAnytime before procedure even just a few hours before.
10Sarah in the ORSarah 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
13Sarah recoversSarah 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?
14Hospital progress Note Brief note concerning past 24 hoursS: 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 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
15Discharge Note Admission/Discharge Dates: 7/2/11-7/5/11 Admission/Discharge Dx: Femoral herniaService: Surgery, Dr. LotheissenReferring Physician: Dr. Rhemy PCPConsult: any physicians, service, datesProcedures: date of surgery/procedure and typeHx, PE: pertinent admission H&P and lab testsCourse: summary of treatment and progressDischarge Condition: good, stable, fair, etc.Medications: discharge meds, dose, refillsInstructions: restrictions, diet, care, symptoms to be aware ofFollow-up: appointment and emergency contact number
16Practice!!! Progress Note So, who wants to send Mr. Sacamano home? Mr. Robert SacamanoSo, who wants to send Mr. Sacamano home?Anything he’ll need to complete treatment?Start 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
18L&D Admit NoteS: 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 strepGYN Hx: age of menarche x interval btw periods x how long periods last (13x28x4); hx of STI, abnl papOB Hx: G_T_P_A_L_List any complications with previous pregnancies/deliveriesPMH: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), ExtSVE: cm / effacement / stageToco:FHT’s:Assessment: ___ yo, G_P__, ___ weeksPlan: Continue monitoring during induction with Pit at ____mu.
19Labor Progress NoteS: Pt resting comfortably and notes increased frequency and strength of ctx.O: BP PAny new observations as to the patients statesFHT:SVE___/___/____Toco: q____min or irregular, doublets or tripletsPit___muA/P: ___yo G__P__at ___wksContinue labor and increasing Pit per protocol, anticipate SVDSVE: sterile vaginal exam (dilation/effacement/height)
20Delivery Note: Vaginal Delivery Type: SVDProcedure: vacuum-assisted, forceps, episiotomy, laceration repairAttending/Assist:Anesthesia: type and personFindings: 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:
21Delivery Note: C-Section Pre-operative Diagnosis: 38 week pregnancy, G1P0Post-operative Diagnosis: 38 wk, G1P1Procedure: Primary C-sectionSurgeon & Assistant: Dr. Will; Assist Student DrAnesthesia: (General, epidural, spinal, etc.)Estimated Blood Loss: 500mLFindings: Include position (especially if breech), gender of infant, weight, APGAR scores, normal uterus, tubes & ovaries or describe if other than normalComplications: if any or “none”Condition: e.g. patient tolerated procedure well, transferred to recovery room in stable condition
22Post-Partum Note Labs: pre post (note if pending) PPD#__ or POD#__ Subjective:Condition of patient: Patient resting comfortably in bedPain: Pain well-controlled, PQRSTLochia: minimal, moderate, or heavy (greater than or less than a period)Breast or Bottle feedingTolerating diet & liquids wellAmbulating with or without assistanceSOB, CP, Flatus, BM, Urinating, LE pain or swellingAsk about birth control optionsObjective:VSRh & Rubella statusHeart: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, tenderUrine output: voiding without difficulty, is Foley in place, urine clearExtremities: swelling, signs of DVT- size or color discrepancy, Homan’s signLabs: 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
23Admission 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
24Admit 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
25DiagnosisDiagnosis: 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
26Condition General condition of patient at time of admission StableGuardedCriticalCode StatusCondition: Stable Code Status: Full Code
27Allergies Allergies: Penicillin; anaphylaxis Medication, food or environmental allergiesBe sure to state the reaction if known
28VitalsVitals: 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
29Activity Restrictions on patients activity Bed restBedside commodeUp Ad LibBathroom privilegesAmbulationUp in chairUp with nurse assistanceFall precautionsSeizure precautionsIsolationActivity: Bathroom privileges, Fall Precautions
30NursingAny 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
31Diet 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
32IV *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
33Medication 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
34Example: 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
35Labs 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
36Special Are there any special orders Respiratory therapy to follow Ancillary servicesRadiologyConsultsSpecial prepsRespiratory therapy to follow
37Admission 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 100.5° 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.
38Admission Orders 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
39Note-Writing Resources Maxwell Quick Medical ReferenceA must-have!! Only $7.95!!Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine (Pocket Notebook)’250 Mistakes 3rd year medical students makeClinician’s Pocket Reference (Scut Monkey)Medfools also has some sample personal statements