d ocumentation in your 3 rd year and beyond summer quarter 2011 amanda kocoloski and whitney crye
TRANSCRIPT
DOCUMENTATION IN YOUR 3RD YEAR AND BEYOND
Summer Quarter 2011
Amanda Kocoloski and Whitney Crye
OVERVIEW General principles of documentation Types of Notes, the case of Sarah Bell
Admit Note Pre-Op Note Procedure Note Operative Report Post-Op Note Progress Note Discharge Summary L&D Admit Note Labor Note
Medication Prescriptions Assignment: Admission Orders
INTRODUCTION TO HOSPITAL CHARTING
Everything must be recorded somewhere!!! When starting a new rotation become
familiar with the chart ASAP Paper vs. EMR
Always: Date, time, and sign with rank
SAMPLE 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?
OUTPATIENT NOTE S: 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: 4/10 CV: S1 S2 no murmurs, no gallops Lungs: clear bilaterally, no wheezes, rhonchi, rales Abdomen: 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 masses LE: 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
SARAH 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?
ADMISSION NOTE/HISTORY & PHYSICAL
CC: Pt is a 35 yo f presenting with a “bulge” in her groin HxCC: 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: HTN PSH: none Meds: HCTZ Allergies: NKDA SHx: non-smoker, no alcohol, no illicit drug use; LPN by profession, married, 2 children FHx: Mom alive, HTN; Dad deceased at 46 of MI with hx of HTN ROS:
General: Skin: HEENT: Chest: Abdomen: GU: Extremities: Neurologic: Hematologic: Psychiatric: Endocrine:
PE: VS General: Skin HEENT: CV: Lungs: GI: GU: Extremity: Neurologic:
Labs/Imaging: pelvic CT showed a femoral hernia of the right groin. No labs ordered as this time. Assessment:
1. Femoral hernia. 2. HTN- controlled
Plan Admission Orders
SARAH PREPS FOR THE OR
Sarah 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?
SURGERY PRE-OP NOTE
Pre-op Dx: femoral herniaProcedure 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
chart
SARAH IN THE OR
Sarah 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?
PROCEDURE/OP NOTES Procedure / Indication: Lotheissen McVay for femoral hernia Permission
I 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 MSIV Estimated Blood Loss (EBL): 2mL Description
Area 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: none Disposition
Pt a/o, resting, breathing quietly, extremities neurovascularly intact. Incision clean, dry, intact. In stable condition.
SURGERY POST-OP NOTE Pre-op diagnosis: femoral hernia Post-op diagnosis: femoral hernia Procedure: Lotheissen McVay femoral
hernia repair Surgeons: Dr. Lotheissen, A. Kocoloski MSIV Findings: femoral hernia at right groin
region with healthy bowel in the hernial canal Fluids: 1000mL lactated ringers Anesthesia: epidural Estimated Blood Loss: 2 mL Drains:none Specimens: none Complications: none Condition/ Disposition: stable
SARAH RECOVERS
Sarah 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?
HOSPITAL 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.
DISCHARGE NOTE Admission/Discharge Dates: 7/2/11-7/5/11 Admission/Discharge Dx: Femoral hernia Service: Surgery, Dr. Lotheissen Referring Physician: Dr. Rhemy PCP Consult: any physicians, service, dates Procedures: date of surgery/procedure and type Hx, PE: pertinent admission H&P and lab tests Course: summary of treatment and progress Discharge Condition: good, stable, fair, etc. Medications: discharge meds, dose, refills Instructions: restrictions, diet, care, symptoms to be
aware of Follow-up: appointment and emergency contact
number
PRACTICE!!!
Progress Note Mr. Robert Sacamano
So, who wants to send Mr. Sacamano home?
Anything he’ll need to complete treatment?
OB PROGRESS NOTES
L&D ADMIT NOTE S: 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 strep GYN Hx: age of menarche x interval btw periods x how long periods last (13x28x4); hx
of STI, abnl pap OB Hx: G_T_P_A_L_
List any complications with previous pregnancies/deliveries PMH: 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), Ext SVE: cm / effacement / stage Toco: FHT’s:
Assessment: ___ yo, G_P__, IUP @ ___ weeks Plan: Continue monitoring during induction with Pit at ____mu.
LABOR PROGRESS NOTE S: Pt resting comfortably and notes increased
frequency and strength of ctx. O: BP P
Any new observations as to the patients states FHT: SVE___/___/____ Toco: q____min or irregular, doublets or triplets Pit___mu
A/P: ___yo G__P__at ___wks Continue labor and increasing Pit per protocol,
anticipate SVD
DELIVERY NOTE: VAGINAL DELIVERY Type: SVD Procedure: vacuum-assisted, forceps, episiotomy,
laceration repair Attending/Assist: Anesthesia: type and person Findings: 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:
DELIVERY NOTE: C-SECTION Pre-operative Diagnosis: 38 week pregnancy,
G1P0 Post-operative Diagnosis: 38 wk, G1P1 Procedure: Primary C-section Surgeon & Assistant: Dr. Will; Assist Student Dr Anesthesia: (General, epidural, spinal, etc.) Estimated Blood Loss: 500mL Findings: Include position (especially if
breech), gender of infant, weight, APGAR scores, normal uterus, tubes & ovaries or describe if other than normal
Complications: if any or “none” Condition: e.g. patient tolerated procedure
well, transferred to recovery room in stable condition
POST-PARTUM NOTE PPD#__ or POD#__ Subjective:
Condition of patient: Patient resting comfortably in bed Pain: Pain well-controlled, PQRST Lochia: minimal, moderate, or heavy (greater than or less than a period) Breast or Bottle feeding Tolerating diet & liquids well Ambulating with or without assistance SOB, CP, Flatus, BM, Urinating, LE pain or swelling Ask about birth control options
Objective: VS Rh & Rubella status Heart: 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, tender
Urine output: voiding without difficulty, is Foley in place, urine clear Extremities: swelling, signs of DVT- size or color discrepancy, Homan’s sign
Labs: 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
ADMISSION ORDERS: ADCA VAN DIMLS
Admit to service of… Diagnosis Condition Allergies
Vital Signs Activity Nursing
Diet IV orders Medications Labs Special
ADMIT
Attending Physicians Name
Unit/Floor: Medical Surgery Medical ICU Surgical ICU
If the family physician is not the same as the attending, you can notify the family doctor as a courtesy.
Admit: Dr. Duerfedlt,
Medical FloorNotify: Dr. D.O. of
patients admission
DIAGNOSIS
List both the diagnosis that caused the patient to be admitted (primary) and any other diagnosis(es) that the patient currently carries
Diagnosis: PneumoniaSecondary Diagnoses:
Hypertension, DM Type 2
CONDITION
General condition of patient at time of admission Stable Guarded Critical Code Status
Condition: StableCode Status: Full Code
ALLERGIES
Medication, food or environmental allergies
Be sure to state the reaction if known
Allergies: Penicillin; anaphylaxis
VITALS
Frequency: How often do you want this patient’s vitals checked Is the patient’s condition
one which you may expect a change over a short period of time?
Parameters When should the doctor
be called
Vitals: 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 officer
ACTIVITY
Restrictions on patients activity Bed rest Bedside commode Up Ad Lib Bathroom privileges Ambulation Up in chair Up with nurse assistance Fall precautions Seizure precautions Isolation
Activity: Bathroom privileges, Fall Precautions
NURSING
Any special functions that the nurse must carry out and frequency if applicable I/O’s Oxygen (some docs put
this other places too) Pulse oximeter Accu checks Drain and/or catheter
instructions Incentive spirometry Wound care Stool guaiac
Nursing: O2 2L via NC titrated to
maintain sats at or above 95%
Continuous pulse oximetry
Accuchecks AC and HSIncentive spirometry q 2
hrs while awake
DIET
State any dietary restrictions NPO (nothing per oral) Ice chips only Clear fluid only Soft Full Thickened liquids 2200 calorie ADA Cardiac Low sodium Low residue Regular diet
Diet: 1800 ADA diet
IV*THIS SECTION IS RESERVED FOR IV FLUID ADMINISTRATION, NOT FOR IV MEDICATIONS*
If ordering IV fluids, state Type of fluid (Normal
Saline, Lactated ringer etc) Additives (KCL, MG) Rate in ml/hr at which fluid
should be run Endpoint for infusion
Maintenance fluids Rehydration Heplock KVO None
IV: 0.9 NS KVO
MEDICATION List medication specific to patients primary
diagnosis List other meds that patient is currently taking that
you want continued throughout admission List PRN medications (i.e. pain, fever) Include dose, mode of administration
Can vary the dosage or the dosing interval, not both
Be sure to include insulin orders here for patients getting Accuchecks
EXAMPLE: MEDICATION
Levaquin IV 650mg q day Tylenol 500 mg PO q 4-6 hr prn HA or fever
greater than 101 Ambien 10 mg PO @ hs prn insomnia Sliding scale coverage of accuchecks using low-
dose algorithm Duo-neb treatments q2hr prn SOB or wheeze Duo-neb tx q 6hours Mucinex 600mg PO Q 6hrs Lisinopril 10 mg PO Q day
LABS
List labs to be done and state when labs should take place
Do 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
SPECIAL
Are there any special orders Ancillary services Radiology Consults Special preps
Respiratory therapy to follow
ADMISSION ORDERSAdmit to: Dr. D on med-surg floorDx: 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.
ADMISSION ORDERS
Diet: 1800 ADA IV: 0.9 normal saline
to KVO
Labs Blood culture: now Sputum culture: now CBC, chem 7: in am
Special: Respiratory therapy to follow
Medications Levaquin IV 650mg qd Tylenol 500mg PO q 4-6 hr
prn HA or fever greater than 101
Ambien 10 mg PO @ hs prn insomnia
Sliding scale coverage of accuchecks using low-dose algorithm
Duo-neb treatments q2hr prn SOB or wheeze
Duo-neb tx q 6hours Mucinex 600mg PO Q 6hrs Lisinopril 10 mg PO Q day
NOTE-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 make Clinician’s Pocket Reference (Scut Monkey) www.medfools.com
Medfools also has some sample personal statements