Hospital Documentation

1. Hospital Documentation H & P Admit Note Admit Orders

2. History and Physical

3. …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

4. SOAP format • Objective – what do YOU find? • Physical • Lab • X-ray • Other studies • Assessment • Plan

5. 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

6. 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

7. ROS • Integument/Skin • HEENT • CV • Pulmonary • GI • GU • Neurologic • Musc/Skeletal • GYN • Endocrine

8. 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)

9. 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

10. H & P • Other – • Lab • X-ray • Other studies • Old record review

11. 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..)

12. Assessment, e.g. • Pneumonia • Hypokalemia • HxHTN (or can say HTN – controlled)

13. 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)

14. Admission (admit) note

15. 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

16. …MUST contain • CC • Hx cc • Pertinent physical (pertinent positives) • Assessment • Plan

17. Admission Orders

18. …Instructions to the Nursing Staff • What do you want done for this patient now that they are coming into the hospital? • Systematic approach

19. Admission Orders • Admit to service of (insert doctor) • Any special floor? (ICU, stepdown, telemetry) • Condition • Allergies • Vitals • Activity • Diet

20. Admission Orders • Medications IV • Medications PO • These include any over the counter as well • Labs • X-ray • Other studies • Other

21. …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

22. 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

23. 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

24. Questions?