Outline

The Patient Chart

Admission Note (History and Physical)

Progress Notes

Discharge Notes

Operative Notes

Pre and post-operative

Procedure notes

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The Patient Chart

Chart is located at the patient bedside,

electronically or at nursing station

Essential components of the chart

Admission notes, physicians Orders, administered

medications, vitals, progress notes, laboratory and

radiographic examinations and discharge summary

The Patient Chart

Important medical and legal document

Need to write legibly and sign your notes !!

Everything you write must be co-signed by and

attending physician or by your senior resident !

Always date, time and sign your notes !

The History and Physical (H+P)

Initial note for a patient admitted to the hospital

Summarizes:

Why the patient came to the hospital

Medical history prior to this admission

Initial physical exam to include initial labs/studies

Gives the physician the opportunity to formulate a

differential diagnosis and treatment plan

The History + Physical (H+P)Tips

Always welcome the patient – ensure comfort

and privacy

Know the patient’s name

Introduce and identify yourself

Set the agenda for the questioning

H+P Components

Chief complaint

History of Present

Illness

Past Medical History

Past Surgical History

Allergies

Medications

Social History

Family History

Review of Systems

Physical Exam

Labs/Studies

Assessment and Plan

Chief Complaint (CC)

This is why the patient is in the Emergency

Room or in the office seeing you “This is in the patients own words”

Examples: Shortness of breath

Chest pain

Nausea and Vomiting

History of Present Illness (HPI)

Detailed reason why patient is here

Use the OPQRSTA approach to cover information

Begin by listing all the relevant major medical

problems in first sentence

Mr. Morris with history of hypertension, diabetes,

obstructive sleep apnea and osteoarthritis presented to

the hospital with ……

OPQRSTA Approach Onset:

When did the CC occur Prior occurrences Progression

Is it getting worse or better?

What makes it better or worse

Quality Is there pain, and if so

how would you describe it?

Radiation of Symptoms

Scale On scale of 1-10, how

bad are the symptoms Timing

When do they occur? Associated symptoms

Any other symptoms not already covered

HPI Continued

Include in this section a brief synopsis of what

was done in the ER or at an outside hospital

Example: 50 year old male with hypertension, diabetes, obstructive sleep apnea and osteoarthritis presented to the hospital complaining of fevers, chills and a cough for the past week. The cough started approximately one week ago, was productive in nature, and had an occasional blood tinge to it. The patient says that the fever and chills began two days ago and has prevented him from sleeping at night. Incidentally, the patient’s brother, who was visiting from Herat, was recently ill with similar symptoms.

Past Medical and Surgical History

Major disease(adult and childhood) with brief discussion of

duration and treatment

Ex: Hypertension x 10 years well controlled on medications,

s/p stroke in 1991 with residual left sided weakness

Hospitalizations (Reason for admissions, when and where?)

Surgical procedures with dates (Indications)

Example: Open Cholecystectomy at age 46

Immunizations

Other Components Medications:

Dosage and duration

Does patient take the

medications?

Over the counter and herbal

medications

Allergies:

Record allergies and reactions

to medications, foods and

latex

No known drug allergies

Social history:

Occupation

Tobacco, alcohol or illicit

drug use

Marital and children status

Family History:

Include inherited diseases

Ex: + Diabetes in mother and

sister

Review of Systems (ROS)

Series of questions based on organ system: General/Constitutional

Skin/Breast

Eyes/Ears/Nose/Mouth/Throat

Cardiovascular

Respiratory

Gastrointestinal

Musculoskeletal

Neurologic/Psychiatric

It is acceptable to write: ROS as per HPI, otherwise

negative

Physical Examination

General (Always include vital signs)

HEENT (Head, eyes, ears, nose, throat)

Heart

Lungs

Abdomen

Extremities

Skin

Neurology

You must do a Physical Examination !!!

Need to develop a systematic approach for doing the physical examination !

Labs and Radiographic Studies

Admission labs and important studies

Example:

Complete blood count

Chemistry panel

Cardiac enzymes

EKG

Chest X-ray

Assessment and Plan

Assessment of the patient:

This is what you think is wrong with the patient

Start with a short summary of 3-4 sentences

maximum

Follow by listing each active problem numerically

with most important first

Assessment and Plan

Assessment of the patient: Each problem you list requires an in depth assessment

which includes a differential diagnosis

Support your thoughts with elements of the patient’s

history, physical, lab results

Plan:Conclude with a detailed treatment plan

Sign your note with resident year and phone number

Example

Plan: The differential diagnosis includes bacterial pneumonia, tuberculosis, viral pneumonia, or less likely pulmonary sarcoid.

1. Pulmonary Infection:- Obtain blood cultures x 3- Obtain sputum cultures and smear x 3- Start appropriate antibiotics for community acquired pneumonia- Initiate primary tuberculosis treatment- Admit to hospital with appropriate isolation precautions: respiratory and droplet precautions

2. Hypertension:- Continue outpatient medications 3. Diabetes:- Continue outpatient diabetic medications- Institute an insulin sliding scale

Assessment: The patient is a 50 year old male with hypertension, diabetes, and obstructive sleep apnea who presents to the hospital with a respiratory infection.

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Progress (SOAP) Notes

Every inpatient should have a daily progress note

in the chart

This note allows you to:

Communicate your thoughts about a patient’s condition

Your treatment plan

And any progress that has been made over the past 24

hours

S= Subjective

Summarizes how the patient feels

Includes pertinent events that occurred

overnight

Look through nursing notes or ask the nurse

about how the patient did overnight

O=Objective

Objective information including:Vital signs

○ Temperature, blood pressure, heart rate, respiratory rate,

oxygen saturation and pain scale

○ I/O (“Ins and Outs”)

Pertinent physical exam findings

More recent labs and diagnostic test results

Current inpatient medications (include # of days on the

medication. For example, Gentamicin (7/14)

A= Assessment

1-2 sentence summary of the prior two

sections which includes:Patient’s age, hospital day (if surgical patient include

post-op day), and disease process

For example:

○ 50 year old male admitted with heart failure ….

○ 50 year old male post-op day # 3 status post

appendectomy ….

P= Plan

This section includes:

What you plan to accomplish over the next 24 hours

including medications, procedures, consults, or

discharges

Again, always sign your notes and provide a contact

phone number

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Discharge Summary

Provides the patient and their outpatient

physicians with:

Brief summary of the patient’s presentation to

the hospital

The hospital course

And any further treatment recommendations

Discharge Summary

Important Components of a Discharge Summary

(see attached example):

List the number one problem for the patient’s admission

List important admission labs, vitals, signs + symptoms of

the patient

Diagnostic work done during the patient’s admission

○ You can write in the discharge summary if there is any

work-up that is still pending at discharge

Need to write down who the patient is to follow-up with …

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Pre-Operative Note

These notes are written on all surgical patients

This is essentially a checklist to confirm all the

required pre-op information has been collected

and patient is ready for surgery

This should be completed in the progress note

section prior to surgery

Pre-Operative Note Format

Date and time

Pre-op diagnosis: Appendicitis

Procedure: Open

Appendectomy

Pre-op Orders: Nothing Per Oral

(NPO)

Labs: CBC, PT/PTT (record

results prior to the procedure)

CXR: No active disease (note the

findings)

EKG: Normal sinus rhythm (note any

abnormalities)

Blood: Typed and crossed for 2

units of O+

Consent: Singed on chart

Anesthesia: To see patient, or

patient seen, note on chart

Operative Note

Pre-op Diagnosis: Appendicitis

Post-Op Diagnosis: Appendicitis

Procedure: Appendectomy (what was done?)

Surgeons: Attending, resident and students

who scrubbed in on the procedure

Findings: acutely inflamed appendix

Operative Note

Anesthesia: general with endotracheal tube,

spinal, local, etc

Fluids: amount and type (electrolytes, blood); also

record the urine output

Estimated blood loss (EBL): amount in cc

Drains: List all in the patient after the procedure

Number, type and location

Operative Note

Hardware: Relevant usually for orthopedics

Specimens: Type of specimen sent to pathology

Complications: List any complications

Needle and sponge count: correct x 2

Disposition: Stable, extubated, transferred to

recovery room

Post-Operative Notes

Post-op checks are progress notes are usually

written 4-8 hrs after completion of case

Documents the patient’s immediate post-op

condition and progress

Use a modified SOAP note

Post-Operative Notes

Status post (s/p): Procedure and indication

S: Subjective

Patient complaints or comments

CHECK consciousness (alert, oriented, drowsy),

ambulating

Taking oral medications

Pain control

Post-Operative Note

O= Objective

Vitals: BP, HR, Respirations, Temp, O2 sat

INS/OUTS: IV fluid, PO intake, drains/tubes

Exam: Physical findings

○ Incisions/dressings -- clean, dry and intact (CDI)

○ Neurovascular status

Meds: Routine or new medications (Antibiotics, DVT

prophylaxis)

Labs: Results of labs since surgery

Post-Operative Note

A/P: Assessment and Plan

Patient is stable/unstable/critical status post

procedure

Include problems and how you plan to address them

Plans for diet, ambulation, dressing changes, fluid

management, foley, drains, pain management and

etc.

Don’t forget to sign your name, date and provide a

phone number

Procedure Note

After performing a procedure:

It is imperative that you document procedures

performed on patients in the patient’s chart

This allows other physicians to know what

occurred and can act if a complication should

arise later in the day

Procedure Note Format

Procedure: What procedure did you do?

Permit:

Document that you explained and patient

understands the procedure

Discussed alternatives, risks, and benefits of the

procedure to the patient

○ Risks: Bleeding, infection, reaction to anesthesia,

general injury, etc)

Procedure Note Format

Indications: Why did you do the procedure?

Physician (s): Who performed the

procedure?

Description: How did you do the procedure?

Where did you do the procedure?

What anesthetic did you use?

Procedure Note Format

Complications: Did anything go wrong with the

procedure, bleeding, pneumothorax, infection?

EBL: estimate the amount of blood loss in cc’s

Disposition: How did the patient tolerate the

procedure?

Where will the patient go after the procedure?

Any Questions ??

References

Maxwell Quick Reference Book. 2006.