Documentation in your 3 rd year and beyond

1. Documentation in your 3rd year and beyond Amanda Kocoloski and Whitney Crye Summer Quarter 2011

2. 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

3. 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

4. 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?

5. 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

6. 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?

7. 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

8. 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?

9. Surgery Pre-Op Note • Pre-op Dx: femoral hernia • Procedure planned: Lotheissen-McVay femoral hernia repair • Labs: CBC, Chem 7, PT/PTT, UA • CXR: deferred • EKG: normal 3 months ago • Blood: type/screen, type/cross • Orders: 1.NPO 2. Antibiotics 3. skin prep • Permission: Informed consent signed/on chart

10. 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?

11. Procedure/Op Notes • Procedure / Indication: LotheissenMcVay 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 transversalisfacia 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.

12. Surgery Post-Op Note • Pre-op diagnosis: femoral hernia • Post-op diagnosis: femoral hernia • Procedure: LotheissenMcVay 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

13. 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?

14. Hospital progress Note • Brief note concerning past 24 hours • S: 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.

15. 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: anyphysicians, 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

16. Practice!!! • Progress Note • Mr. Robert Sacamano • So, who wants to send Mr. Sacamano home? • Anything he’ll need to complete treatment?

17. OB Progress Notes

18. L&D Admit Note • S: This ___year old female, wks, GP, EDDbased 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.

19. 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: ___yoG__P__at ___wks • Continue labor and increasing Pit per protocol, anticipate SVD

20. 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:

21. 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

22. 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

23. Admission Orders: ADCA VAN DIMLS • Admit to service of… • Diagnosis • Condition • Allergies • Vital Signs • Activity • Nursing • Diet • IV orders • Medications • Labs • Special

24. 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 Floor Notify: Dr. D.O. of patients admission

25. Diagnosis • List both the diagnosis that caused the patient to be admitted (primary) and any other diagnosis(es) that the patient currently carries Diagnosis: Pneumonia Secondary Diagnoses: Hypertension, DM Type 2

26. Condition • General condition of patient at time of admission • Stable • Guarded • Critical • Code Status Condition: Stable Code Status: Full Code

27. Allergies • Medication, food or environmental allergies • Be sure to state the reaction if known Allergies: Penicillin; anaphylaxis

28. 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

29. 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

30. 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 HS Incentive spirometry q 2 hrs while awake

31. 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

32. 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

33. 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

34. 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

35. 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: now Sputum culture: now CBC, chem 7: in am

36. Special • Are there any special orders • Ancillary services • Radiology • Consults • Special preps Respiratory therapy to follow

37. Admission Orders • Admit to: Dr. D on med-surg floor • Dx: pneumonia • Secondary Diagnoses: HTN, DM type 2 • Condition: stable • Allergies: Penicillin- anaphylaxis. • Vitals: q shift (every 8 hours) If temp is greater than 100.5° call attending • Activity: Bathroom privileges, fall precautions • Nursing: 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.

38. 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 @ hsprn 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

39. Note-Writing Resources • Maxwell Quick Medical Reference • A 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