hospital documentation

Hospital Documentation

H & PAdmit 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?

• Physical• Lab• X-ray• Other studies

• Assessment• Plan

H & P • 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)

• Any special floor? (ICU, stepdown, telemetry)• Condition• Allergies• Vitals• Activity• Diet

Admission Orders• Medications IV• Medications PO

• 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

• 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?