DOCUMENTATION IN YOUR 3RD YEAR AND BEYOND

Summer Quarter 2010

Merrian Brooks and Amanda Kocoloski

OVERVIEW General principles of documentation Types of Notes, the case of Ineda Surgery Admission Orders

INTRODUCTION TO HOSPITAL CHARTING

EVERYTHING must be written somewhere!!! H&P, progress notes, labs, orders Paper vs. EMR Example charts

SAMPLE PATIENT: INEDA SURGERY

Ineda 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?

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 denies discomfort. Last bowel movement yesterday. 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, good excursion, good air

movement Abdomen: flat, bowel sounds present, no rebound, no

guarding, soft, irreducible mass in right groin below inguinal ligament appreciated, no erythema, no pain with palpation

GU: no labial masses A/P: 35 yo f with femoral hernia. Plan:1. admit to

hospital 2. consult surgery

INEDA GOES TO THE HOSPITAL

Ineda 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?

ADMISSION NOTE

Full H&P related to CC Add a sentence (or 3) about the ER course

While in the ER pt received 200mg of ibuprofen, and a pelvic CT scan that showed a femoral hernia of the right groin.

Assessment Pt has an irreducible mass beneath inguinal ligament

that is also evident on CT consistent with a femoral hernia.

Plan Admission orders

Other elements may include: informant and reliability, development/immunization (peds), problem list (complex pt)

INEDA PREPS FOR THE OR

Ineda 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?

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. skin prep Permission: Informed consent signed/on

chart,

INEDA IN THE OR

Ineda 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?

PROCEDURE/OP NOTES Procedure / Indication: Lotheissen McVay 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 transversalis facia 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.

SURGERY POST-OP NOTE Pre-op diagnosis: femoral hernia Post-op diagnosis: femoral hernia Procedure: Lotheissen McVay 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

INEDA RECOVERS

Ineda is now post op and resting. You arrive at 4 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?

HOSPITAL PROGRESS NOTE

Brief note concerning past 24 hoursS: Pt did well overnight. Pain controlled with

ibuprofen. Passed gas, no bowel movement.O: VS most recent; Exam: CV, Lungs, Abdomen,

GU; 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 ibuprofen for pain management. Advance diet as tolerated. Continue to monitor I/O. Performed pedal pump and strain counter strain of both lower extremities, pt tolerated well.

PRACTICE!!!

Group 1. Hospital Progress Note A

Group 2. Procedure Note: http://www.youtube.com/watch?v=R2_0gOI8uV0&feature=related

Group 3. Hospital Progress Note B

ADMISSION ORDERS: ADCA VAN DIMLS

Admit to service of… Diagnosis Condition Allergies

Vital Signs Activity Nursing

Diet IV orders Medications Labs Special

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 FloorNotify: Dr. D.O. of

patients admission

DIAGNOSIS

List both the diagnosis that caused the patient to be admitted (primary) and any other diagnosis(es) that the patient currently carries

Diagnosis: PneumoniaSecondary Diagnoses:

Hypertension, DM Type 2

CONDITION

General condition of patient at time of admission Stable Guarded Critical Code Status

Condition: StableCode Status: Full

Code

ALLERGIES

Medication, food or environmental allergies

Be sure to state the reaction if known

Allergies: Penicillin; anaphylaxis

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

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

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

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

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

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

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

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

SPECIAL

Are there any special orders Ancillary services Radiology Consults Special preps

Respiratory therapy to follow

ADMISSION ORDERSAdmit to: Dr. D on med-surg floorDx: pneumonia

Secondary Diagnoses: HTN, DM type 2Condition: stableAllergies: Penicillin- anaphylaxis. Vitals: q shift (every 8 hours) If temp is

greater than 102° call attendingActivity: Bathroom privileges, fall

precautionsNursing: 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.

ADMISSION ORDER

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 @ 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

NOTE-WRITING RESOURCES

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