EVERYTHING YOU EVER WANTED TO KNOW ABOUT NOTES

I.E. INTRODUCTION TO DOCUMENTATION SO DEBORAH MACK WILL LEAVE YOU ALONE SO YOU CAN ANSWER OTHER NON-EMERGENT PAGES

Bill Beck with a fist-bump to Rondi Kauffmann MD, MPH7.2.2010

H&PReferring physicianCCHPI (4+)PMHPSH MedicationsAllergiesFamily HistorySocial History

H&PROS (10+)

List by systemOr, state “10 systems were reviewed and were negative except for…”

Exam (8+ systems)VitalsLabs

RadiologyPathologyAssessmentPlan

H&PHPI elements:

LocationQualitySeverityDurationTiming ContextModifying FactorsAssociated signs and symptoms

H&PROS elements

Constitutional-fever, weight lossEyesEars, Nose, MouthThroatCVRespiratoryGIGUMusculoskeletalSkinNeuroPsychHeme/lymphAllergic/immunologic

H&PExam elements:

ConstitutionalEyesEyes, Nose, Mouth, ThroatCVRespiratoryGIGUMusculoskeletalSkinNeuroPsychHeme/lymphatic

CLINIC NOTEFull H&PFollowup clinic visit

Chief complaintInterval history New labs/imagingExam (8 organ systems)AssessmentPlan

CPT Code 99241 99242 99243 99244 99245History (3 of 3)

HPI 1 - 3 1 - 3 4+ 4+ 4+ROS None 1 2 - 9 10+ 10+PFSH None None 1 All 3 All 3EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems 8+ systems

Decision (2 of 3) Straighforward Straightforward Low Moderate High#Dx/Options 1 1 2 3 4

Amt. Data/Complex 0 - 1 0 - 1 2 3 4Risk Level Minimal Minimal Low Moderate High

TIME 15 minutes 30 minutes 40 minutes 60 minutes 80 minutes

CPT Code 99201 99202 99203 99204 99205History (3 of 3)

HPI 1 - 3 1 - 3 4+ 4+ 4+ROS None 1 2 - 9 10+ 10+PFSH None None 1 All 3 All 3EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems 8+ systems

Decision (2 of 3) Straighforward Straightforward Low Moderate High#Dx/Options 1 1 2 3 4

Amt. Data/Complex 0 - 1 0 - 1 2 3 4Risk Level Minimal Minimal Low Moderate High

TIME 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes

CPT Code 99211 99212 99213 99214 99215History (3 of 3)

HPI 1 - 3 1 - 3 4+ 4+ROS None 1 2 - 9 10+PFSH None None 1 2EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems

Decision (2 of 3) Straightforward Low Moderate High#Dx/Options 1 2 3 4

Amt. Data/Complex 0 - 1 2 3 4Risk Level Minimal Low Moderate High

TIME N / A 10 minutes 15 minutes 25 minutes 40 minutes

Elements of HPILocation Head, Face Constitutional-fever, wt lossQuality Neck EyesSeverity Chest, Breasts, Axillae Ears, Nose, Mouth, ThroatDuration Abdomen CardiovascularTiming Genitalia, Groin, Buttocks RespiratoryContext Back, Including spine GastrointestinalModifying Factors Each Extremity GenitourinaryAssociated Signs and Symptoms Musculoskeletal

IntegumentaryNeurological PsychiatricEndocrineHematologic / LymphaticAllergic / Immunologic

Constitutional (vital signs, etc.) Respiratory SkinEyes Gastrointestinal NeurologicEars, Nose, Mouth, Throat Genitourinary PsychiatricCardiovascular Musculoskeletal Heme/Lymph/ Immunologic

CLINIC CONSULT (3 of 3)

CLINIC NEW PATIENT (3 of 3)

Organ Systems for Exam

CLINIC ESTABLISHED PATIENT (2 of 3)

Reserved for non-hospital

based practice

Systems for ROSBody Area for Exam

DAILY PROGRESS NOTEName of procedure, post-op daySubjectiveVitalsPhysical exam

Document 5 organ systemsLab and microbiology dataMedications, i.e. antibiotic day #1Assessment

diagnosesPlan

FROM CATHY HALSEY……“As a coder/billing person, I don’t need the past history carried over (cloned) each day. Instead, I need to see what happened since the last note, what your concerns are for the day, is the patient’s condition stable, improving or declining and if you plan to order additional testing, surgery, etc.”

SICU NOTEName of procedure, post-op day24 hour eventsSubjectiveVitalsDripsVentilator settingsPhysical ExamLabs and microbiology data

SICU NOTEAssessment and plan

NeuroCVPulmonaryFEN/GIRenalHemeEndocrineIDProphylaxisOther-lines, catheters, dispo

IMMEDIATE POST-OP NOTE- STARFORM

Start/stop timePreoperative diagnosisPostoperative diagnosisSurgeonAssistantsAnesthetic techniqueImportant findingsComplicationsDrainsFluid managementEBLPatient disposition and conditionSpecimens

OPERATIVE NOTEPre-op diagnosisPost-op diagnosisSurgeonAssistantsOperative procedure performedAnesthetic techniquePre-op indications for procedure

OPERATIVE NOTEProcedure

PositioningIncisionFindingsTechniqueType of closureDrains

ComplicationsSponge and needle countsFluid managementEBLPatient disposition and condition at end of case

POST-OP CHECKGoal: Identify potential problems earlyRationale: Immediate post-op period is a time of significant physiologic stressSequence:

Introduce yourself, ask how they are Check vital signsAsk specifically about the following:

POST-OP CHECKPainChest painSOB

Did they have a post-op CXR?Nausea/vomitingOperation specific problems:

Carotid endarterectomy: BP control, neurologic compromise, neck hematomaThyroid/Parathyroidectomy: neck hematomaGastric bypass-tachycardiaVascular-pulse exams

POST-OP CHECKExamine patient

Heart/lungs/operative siteDrains- nature and output

Review post-operative ordersPain medsAnti-emeticFluidsGI prophylaxis/ DVT prophylaxisIS to bedside

Review post-op labsAnswer patient questions

POST-OP CHECK ‘DON’TS’Don’t relate operative findings unless discussed with senior residentDon’t ignore warning signs or complaints. Get appropriate workup or call senior resident if unsureDon’t transfuse, give diuretic, or change diet without checking with senior residentDon’t forget to write a post-op note in the chart.

DISCHARGE SUMMARYAttending surgeonDate of admissionDate of dischargeDiagnosesProcedures performedHistory/physical exam/labs on admissionHospital courseDischarge instructions

MedsFollow-upActivityDietStudies

Condition at discharge

ACUTE EVENT NOTEBackgroundSituation upon arrival

Who presentVitalsPatient conditionExam

Actions takenPatient responseFinal dispositionInform attending and senior resident

DEATHDeath Note

Date of admission/deathFloor/unitCause of deathDiagnosesAnticipated?Medical Examiner’s case?Hospital courseAutopsy requested?Family member notified

Inform medical examinerCertificate of DeathInform familyInform attending