Hospital Documentation H & P Admit Note Admit Orders

History and Physical

…is the FULL work up SOAP format Subjective – What is the patient telling you? Chief Complaint History of Chief Complaint Review of Systems Past medical history Past surgical history Family history/social history Allergies/meds

SOAP format Objective – what do YOU find? Assessment Plan Physical Lab X-ray Other studies Assessment Plan

H & P Chief Complaint History of Chief Complaint CC If using patients’ words, use “quotations” Ok to summarize History of Chief Complaint HCC or HxCC or HxPI “quotations” if using patients’ words Note if history is coming from someone other than the patient themself

H & P cont. Past medical/surgical history Review of Systems ROS Pertinent positives AND negatives Get into a “flow” Is ok to have cheat sheets

ROS Integument/Skin HEENT CV Pulmonary GI GU Neurologic Musc/Skeletal GYN Endocrine

H&P cont Family History/Social History/Job/Religion Include habits here – smoking, alcohol, drugs Medications Don’t forget over the counter, vitamins and herbal supplements Need to ask – most patients don’t consider these “meds” Allergies And what is the actual allergy (so you can distinguish from a side effect)

H & P Physical Exam Again, use a logical flow ALWAYS start with vital signs BP, pulse, resp, temp, height, weight OK to use cheat sheet here as well Chart pertinent positives and negatives Don’t make up acronyms RRR is standard c/r/g/m/ is NOT

H & P Other – Lab X-ray Other studies Old record review

H & P Assessment What does your physical and the lab, etc., lead you to find? Ok to use symptoms if don’t have full diagnosis DON’T use the OSCE format No need to put 4 diagnoses here If they have a history of something can put it here, but should NOT be the first listed (and you want to make sure state Hx of..)

Assessment, e.g. Pneumonia Hypokalemia Hx HTN (or can say HTN – controlled)

Plan – What are you going to do with the patient? Admit Start IV antibiotics Replace electrolytes (correct electrolytes, etc) Consult Pulmonary – anticipate bronchoscopy (ok to write see orders) Ok to write discussed the case with Dr. X (seen with Dr. x present, etc)

Admission (admit) note

Admit Note What you put as your first progress note Abbreviated version of H & P Can be the full H & P Entitle “Admit/H &P” No need to duplicate

…MUST contain CC Hx cc Pertinent physical (pertinent positives) Assessment Plan

Admission Orders

…Instructions to the Nursing Staff What do you want done for this patient now that they are coming into the hospital? Systematic approach

Admission Orders Admit to service of (insert doctor) Condition Any special floor? (ICU, stepdown, telemetry) Condition Allergies Vitals Activity Diet

Admission Orders Medications IV Medications PO Labs X-ray These include any over the counter as well Labs X-ray Other studies Other

…so for our pneumonia ATSO Dr. Gail Feinberg Condition – stable NKDA Vitals (q 4 hours, q shift) Activity – ABR with BRP (Absolute Bed Rest with Bathroom Privileges) Ambulation with assistance, no limitations, etc

Pneumonia cont Diet – regular as tolerated (1800 cal ADA, salt restricted, cardiac – check with hospital to see how these are categorized) Medications IV – 1000cc D5W.5NS с 40meq KCL/liter @ 75cc/hr Rocephin 1gm IV daily (DO NOT USE qd) Xopenex nebs q8 hrs

Pneumonia cont Labs CXR – PA and Lateral Other Blood Culture prior to first dose IV antibiotic, sputum culture, CBC, CMP CXR – PA and Lateral Other Oxygen per protocol (2liters NC, only at hs…) Chest percussion after neb treatments Incentive spirometry q shift

Questions?