1. Hospital Documentation
H & P
Admit Note
Admit Orders

2. History and Physical

3. …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

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

5. 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

6. 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

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

8. 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)

9. 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

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

11. 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..)

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

13. 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)

14. Admission (admit) note

15. 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

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

17. Admission Orders

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

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

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

21. …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

22. 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 75cc/hr
Rocephin 1gm IV daily (DO NOT USE qd)
Xopenex nebs q8 hrs

23. 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

24. Questions?