writing with purpose - school of medicine | university of

Writing with purpose

Make IT real and simple

2017-2018

Omar S. Darwish, MS, DO Health Science Assistant Professor Coordinator of the M&M Dept of Med Hospitalist University of California, Irvine

On the Medicine Wards for Medical Students, Interns, and Residents

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Objectives

• History and Physical Medicine Admission Note

• Progress Note

• Discharge Note

Department of Medicine

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Objectives

(I) For the H/P notes…

• In the history section, focus your documentation on the elements of the complaint

• in addition to providing a comprehensive exam, also documenting pertinent positives and negatives in your exam

• providing a problem lists that reflects the active issues and the stability of the comorbidities and providing an “active” plan


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Writing notes…

Tiresome, Monotonous, Boring

Time Consuming

No one reads it anyway

Gets in the way of patient care


Tell us how you really feel

5 Department of Medicine

Problem

Failure to Communicate Active Plans of the Day

Failure to Keep up with the Note

Failure to Reflect The Amount of Work Done

Barriers

High Turnover High Census Academic commitments and too

many necessary/unnecessary Interruptions


READ MY NOTES

I WANT TO SHOW OFF MY KNOWLEDGE & ACTIVITY

Change of attitude

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History Section of the H/P and Progress Note


H&P Document (Comprehensive History)

• Focus on the Elements of the Chief Complaint

or the reason for admission. (Stop Writing the

List of Past Medical Problems)

• PMH Connection

• Are there prior Hospitalization

• 10 System ROS: A few needs to be

documented, but then the statement ”all other

systems are negative” needs to follow.

• PMH/Surgical History, Family History (CANNOT

WRITE NONCONTRIBUTORY), Social History

Progress Note (Detailed History)

• Daily assessment of how their chief complaint

is doing. Great place to ask the patient if they

are in pain (rate it, where is it, associated

symptoms) and are pain meds helping

• ROS: At least 2 are needed

Detailed Hx: 4 HPI elements or the status of 3 chronic medical problems + 2 ROS Comprehensive Hx: Same as above except + 10 ROS + Complete PFSH

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EXAM Section of the H/P and Progress Note


H&P Document (Comprehensive Exam)

• 1 bullet from each of the organ systems (8 pts)

• Example: • Vitals: BP 120/80, HR 60, RR 23, T 98.6

General: NAD, alert and oriented x 3

Constitutional System

1 bullet for vital signs, 1 bullet for general appearance

Progress Note (Detailed Exam)

• 5 bullets from any organ system

Progress Note (Expanded Problem Focused Exam)

• 2-4 bullets from any organ system

Vital signs: 120/80, P 67, RR 18, T 38 (constitutional +1) Gen: NAD (psycho +1) and A&O x 3 (neuro + 1) Heart: RRR no m (cardio + 1) Lungs: CTAB (pulm + 1)

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Imaging and EKG


Cutting and Pasting Imaging Findings & Impressions are Discouraged. Best thing to write is your interpretation, then if you are in agreement or question radiologist impression

Why? Clutters the progress notes & for Discharge Summaries abnormalities listed maybe become a LIABILITY

Example: CXR: my interpretation R large pleural effusion consistent with radiology impression


Assessment/Plans

• By far the most difficult section to write

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Medical Decision Making (MDM)

Overall MDM Problem Points Data Points Risks

Straightforward 1 1 Minimal

Low 2 2 Low

Moderate 3 3 Moderate

High 4 4 High


For High MDM; Requires 2 out of the 3 of the following 1) Four Problem Points 2) Four Data Points 3) High Risk


Problem Points

Problems Points

Self-limited or minor 1

Established problem, stable or improving 1

Established problem, worsening 2

New problem, with no additional workup- planned 3

New problem, with additional workup planned 4

Example: 1. Atrial Fibrillation with RVR- etiology from HTN, hemodynamically stable, new diagnosis 2. Type 2 Diabetes with peripheral neuropathy – stable, at hospitalized blood sugar goal on Lantus 30 U/day and Neurontin 300 bid. 3. Hypertension with cardiac disease- controlled on Norvasc 5 mg qday 4. Moderate Risk for DVT on Lovenox 40 SQ day. Overall Plan/ For new Atrial Fibrillation, start Metoprolol 25 bid, check thyroid panel, obtain echocardiogram, start NOAC

6 pts

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Data Points


Data Reviewed Points

Review or order clinical lab tests 1

Review or order radiology test (except heart cath or echo) 1

Review or order medicine test (PFTs, EKG, cardiac echo or cath) 1

Discuss test with performing physician 1

Independent review of image, tracing or specimen 2

Decision to obtain old records 1

Review and summation of old records 2

Example: 1. Atrial Fibrillation with RVR- etiology from HTN, hemodynamically stable, new diagnosis 2. Type 2 Diabetes with peripheral neuropathy – stable, at hospitalized blood sugar goal on Lantus 30 U/day and Neurontin 300 bid. 3. Hypertension with cardiac disease- controlled on Norvasc 5 mg qday. 4. Moderate Risk for DVT on Lovenox 40 SQ day Overall Plan/ For new Atrial Fibrillation, start Metoprolol 25 bid, check thyroid panel, obtain echocardiogram, start NOAC

2 pts

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Risk: Requires ONE element in ANY of the following three categories

1. Type of Presenting Problem (MODERATE: e.g. mild COPD exacerbation; HIGH: acute hypoxic hypercapnic respiratory failure due to COPD)

2. Type of Diagnostic Procedure (MODERATE: EGD without risk factors; HIGH: EGD with risk factors)

3. Type of Management Options (MODERATE: Prescriptions; HIGH: Prescriptions requiring close monitoring


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So How Should We Write the Note?

• An integrated problem lists with or without a line plan

• Adding a Discussion paragraph maybe needed to explain a complicated case

• Ending with an overall plan that shows current activity for that day


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Example 1: of a Note on Day 30


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Example 1 of a Note Day 31


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Example 1: Apply the New Way of Writing


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Example 2


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Example 2


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Example 3. How To Apply from Day to Day


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Do NOT Write

DM2 or DM

HTN

Anemia

Malnutrition

Hypokalemia

CHF

Cellulitis

Assessment of Common Medical Conditions (Degree, Complications). Be Specific (Location Matters)

Please Write (e.g.)

Type 2 diabetes with peripheral neuropathy

Hypertension with heart disease and CKD stage III

Microcytic Anemia with blood loss

Severe Protein Calorie Malnutrition (MCC*)

Severe Hyperkalemia due to urine loss

Acute on Chronic Systolic Heart Failure (MCC*)

R foot cellulitis


*MCC: Major complication or comorbidity; others include Acute Renal Failure, Acute Respiratory Failure, Acute CHF, hyponatremia, functional quadriplegia Protein Calorie Malnutrition

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Use Non-Definitive Words

• Apply words like Presumed, Probable, or Possible when treating conditions you are not sure about.

• Example: Presumed Gram negative and MRSA Pneumonia – on Vancomycin and Zosyn. The following day you could say Pneumonia Ruled Out – stop antibiotics


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Choose the Diagnosis that Best Reflects Severity

A. Cellulitis

B. Sepsis

C. Septic Shock


Answer: Sepsis Sepsis due Cellulitis

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A. Pneumonia

B. Severe Sepsis

C. Acute Hypoxic Respiratory Failure


Answer: Acute Hypoxic Respiratory Failure due to Severe Sepsis from presumed Gram Neg. Pneumonia

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A. Diabetes

B. Type 2 Diabetes

C. Type 2 Diabetes with peripheral neuropathy

D. Type 2 Diabetes with CKD stage III and peripheral neuropathy, retinopathy, and history of R toe amputation


Answer: D Make connections


READ MY NOTES

I WANT TO SHOW OFF MY KNOWLEDGE & ACTIVITY

Change of attitude


Assessment/Plans

• Reflect your knowledge • Reflect your activity for that day • Overall show that you are committed in

providing the best care

writing with purpose - school of medicine | university of

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