Lynn JacobsSvetlana Yedreshteyn

Organizational Development & LearningJuly 15th, 2009

A Briefing on Electronic

Progress Notes

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Electronic Progress Notes

• Current method is going away

• Progress notes, to date, have been inadequate and, at times, dangerous

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Inconsistent Documentation

A patient acutely deteriorates and codes. He is admitted to the MICU and his wife is called. Upon hearing he is in the ICU on a ventilator the wife asks why we didn’t follow his living will. The patient’s end of life wishes were documented on a prior admission but not in the current chart. Additionally, while the attending knew the patient’s wishes, the information was not included in a progress note.

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Benefits of New Solution

• More succinct, clinically relevant, and factually correct progress notes

• Notes will be available when you need them

• You will no longer have to print out notes

• Improved communication and coordination among members of the healthcare team

• It will be easier to support appropriate levels of billing

• Notes will be configured to each specific service

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Impact of Current Practice

• Cost of unnecessary settlements

• Cost of legal fees

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Hoping and Waiting

Patient is admitted to the PACU after major abdominal vascular repair. Pulses at the end of the case are absent in both lower extremities. The surgeon expects pulses will return in the immediate post-operative period but does not document this or document a clear follow up plan. Nursing and surgical residents accept the patient’s absent pulses as expected and do not call the attending when the patient’s extremities deteriorate from lack of blood flow. When the attending returns to see the patient there is myonecrosis and bilateral amputation is indicated. Family declines the procedure and patient goes on to die.

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The Verbal Report

Patient’s AICD is turned off in the OR but not documented. Verbal report is given to the PACU that the AICD is off. RN questions resident who says it’s OK to transfer the patient. Resident says no problem as she is sure someone would have told her if she needed to turn the AICD back on. Patient is transferred to the floor and sustains a V-tach arrest that is caught on telemetry in a timely manner. The AICD had not been turned back on.

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Note #1Subjective/ObjectiveSubjective/Objective:Pt states that he feels well. No SOB, states that he feels no pain in his leg, and has been

walking around with PT. O: no events overnight. Gen: lying in bed, NADPulm: coarse breath sounds, no cracklesCV: S1S2+, no M/R/G, irregularly irregular rhythmAbd: soft, NT/ND, BS+Ext: legs no longer edematous, erythema over RLE approximately same as yesterday.

Lab Results SectionRoutine Hematology9/18/2008 7:05 White Blood Cells 8.1 Nucleated RBCs 0 Red Blood Cells 2.71 Hemoglobin 8.7 Hematocrit 25.6 MCV 94.4 MCH 32.0

RDW 12.5 Platelets 411 MPV 7.49 Neutrophils 65 Lymphocytes 18 Monocytes 11 Eosinophils 5 Basophils 1 Absolute Neutrophils 5.3 Absolute Lymphs 1.4 Absolute Monocytes 0.9 Absolute Eosinophils 0.4 Absolute Basophils 0.1

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Note #1 (continued)

Assessment/Plan

Assessment/Plan:90M h/o CHF, COPD (on home O2), HTN, CRI (baseline Cr 2.2-2.6), BPH,

hypothyroid, PAF, p/w RLE pain x1day. In ED, febrile to 102, in Afib with HR of 110. Pt received 500 cc NS bolus and IV dilt in ED, RLE found to be edematous, swollen; likely cellulitis. LE duplex negative, BCx positive for Acinetobacter in 2/2 bottles, sensitive to Unasyn, Cipro. Sputum Cx pos for MRSA.

ID - cellulitis, Acinetobacter bacteremia- leg improving slowly, seems to continue to improve off AbxCV - CHF, PAF- will continue to monitor I/O's, daily weights- continuing Lasix 40 mg PO q12h- continuing norvasc 5 mg daily Pulm- pt breathing well, will cont chest PT and nebs endo- TSH normal, continuing synthroid at current dose- continuing insulin sliding scale for hyperglycemia- urine albumin:creatinine ratio elevated 

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Note #1 (continued)

Assessment/PlanGU- continuing proscar, flomax Heme- anemia w/u consistent with iron deficiency, but anemia is macrocytic

with normal RDW; B12/folate normal, will give iron PO- heme consulted, will f/u on recs for rest of MM/lymphoma workup as

outpt (BMBx)PPx- DVT: HSQ 5000 units Q8H- on PPI, will attempt to determine whydispo- plan to D/C home with services on 9/19, tomorrow if okay with heme -

will attempt to reinstateHHA today- appreciate rehab consult recs- full code. Handwritten attending notes stated not iron deficiency

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Note #2Interval HistoryNo events overnight. No dyspnea. Ambulating.Vital Signs(input from ICIS)Physical Exam:Pulm: Unchanged from prior (Coarse BS)Ext – Unchanged from prior (RLE erythema, no edema)Labs:Notable for normocytic anemia and thrombocytosisStable renal insufficiencyNo other diagnositic testsRehab and Heme consults noted and appreciated. Heme eval to be completed

as an outpatientDiagnosis/Problem/PlanCellulitis with Acinetobacter bactermia– betterMonitor off antibiotics; skin careCHF Diastolic – acute-on-chronic – better

Continue furosemide 40mg PO q 12 hours

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Note #2 (continued)Afib – unchanged

Rate controlled,Anemia – acute – unchanged

Follow up with hematology as outpatient for further evalCOPD – chronic – unchanged

Continue O2 via nasal canula, chest PTHTN – chronic - unchanged

Continue NorvascChronic renal insufficiency – unchanged

StableHypothryoidism – chronic – unchanged

Stable on current synthroidRisk for DVT – acute – unchangedContinue SC Heparin 5000U Q8Goals towards discharge

Ambulatory on oral meds with home services in placeProgress toward meeting discharge goals

Awaiting home services

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Interval History is the first section of the progress notes for attending MD, fellow and medical student

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Hovering over book icon will display reference of document, date, time vital sign values where entered.

Automatically retrieves most recent vital signs entered by nursing & others.Looks back 48 hours, otherwise it’s blank. You can enter vital signs taken by you.

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If there is no change from previous day, then select “retrieve previous data”; text box will auto populate with previous data (if any) entered by AUTHOR.

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If Lab Results are reviewed, additional selections display and becomes mandatory.Comments text box also displays.

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Text box for Other Diagnostic comments

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Multiple selections allowed plus a type in space for others.

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Text box automatically populates with previous data entered by AUTHOR.If worse, unchanged or better is selected, data will persist until it is resolved or ruled out.

Plan is always blank. Selecting ‘Previous plan remains the same’ will auto populate previous data (if any) entered by AUTHOR.

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Displays 5 additional diagnosis/problems/plans.

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Text boxes will be populated by most recent data ( if any) entered by AUTHOR .

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Attending MD’s progress note statement of collaboration/supervision

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PROGRESS NOTES MEDICINE

        

Effective July 1, 2009, the Medicine Service will enter all progress notes in ICIS.

This initiative moves us closer to the goal of achieving a paperless environment and above all, improving the quality of our documentation.

 The structured progress note has been configured to each specific role for the Medicine Service (e.g. an attending or fellow’s note will NOT have a hospital course entry whereas the resident/interns note will). Eventually, other services progress notes will also be configured specifically to each service.

Please note that manual copy forward will be suppressed in the new progress note.  To expedite note completion, the system will copy forward predefined sections of the exam, problem list, and discharge criteria.  

It is highly recommended that you start the process of documenting care for the patient by viewing documentation done by other clinicians the previous 24hrs (or greater), via the Clinical Summary Tab. Selecting Physician View will display VS, Current Medications, Lab Results, Other Ancillary Results, Consult Notes and Progress Notes.  From the Progress Note tile, you have the option of viewing the content and or enter a new note.