Medical Documentation

New York Medical College

Stephen Moshman, MD, FACP

and Oral Presentations

Written Communication

• Admission notes• Progress notes• Consults• Discharge

summaries• Letters for patients, jobs, insurance companies• Diagnostic requisitions and reports

Goal of Written Notes

To provide a durable form of communication in a standardized format so any clinician can readily identify the particular patient scenario

What does a written note say about the physician/student?

• Reflects types of patients seen • Reflects ability to obtain accurate data (H & P) • Reflects knowledge base

• Reflects diagnostic and therapeutic reasoning

• Reflects aspects of professionalism (thoroughness, appropriateness, legibility)

Format of Classical Write-up• Chief complaint• History of present illness• Past history (medical, surgical)• Medications/Allergies• Family history• Personal/Social history• Review of systems• Physical exam• Laboratory and ancillary data• Problem List, with Assessment and Plan

Chief Complaint

Should be in patient’s own words (unless otherwise noted)

Common pitfalls:• Omitted

• Exhaustive

• Inappropriate use of medical jargon

History of Present Illness Tells a chronological history of the chief

complaint, in medical language, with both positives and negatives

Explores the chief complaint in a way that follows a preliminary differential diagnosis

May include pertinent details from the rest of the history (PMH, FH, SH, ROS)

Use that section of the ROS suggested by the Chief Complaint as the matrix for the HPI - - this will reflect the preliminary differential diagnoses and guarantee all issues are addressed

History of Present Illness - pitfalls

• Haphazard chronology• Working diagnoses are unclear• Non-pertinent items from the rest of the

history are included• Medical jargon used incorrectly

• Inappropriate abbreviations used

Past History Medical - - important illnesses (with dates of onset),

hospitalizations (with dates), how these illnesses have affected functional capacity. Should

specifically affirm or deny certain illnesses of epidemiologic importance (diabetes, hypertension, heart, lung or renal disease) if not in HPI

Surgical - - operations (with dates and place), accidents, injuries

OB-GYN history (in females) Recent travel history Health maintenance / immunizations

Medications and Allergies Medications - - with dosages and

frequency Allergies - - with type of reaction Common pitfalls:

• Omits OTC or alternative remedies• Does not estimate frequency or

dosing of PRN medications• Does not note recent changes

Family History Try to relate to Chief Complaint/HPI Include only primary relatives, unless other

contact issues are involved Genogram may be useful for inheritable diseases

Should specifically affirm or deny certain illnesses of epidemiologic importance (as with the PMH)

Personal/Social History

Health habits/risk factors (smoking, drinking, drugs, exercise)

Occupation/functional status

Place of birth /Cultural background/ Education

Home situation / Social support

Sexual history

Review of Systems A review of symptoms by organ system to

seek any information that might be related to the current illness, or to uncover other medical problems

Common pitfalls:• Burying actual diseases in the ROS.

They belong in the PMH. • Repeating information already in the HPI

Physical Exam

Should be carried out to explore and support the differential diagnosis

Common pitfalls:• Not focusing on the patients’ symptoms

or the differential diagnosis• Incomplete or inadequate maneuvers• Not heeding patient comfort

Laboratory and Ancillary Data

Needs to explore and support the differential diagnosis

Common pitfalls:• Data is not focused on the

problem(s) at hand• Incomplete documentation (e.g.: “CXR

unremarkable”)

Assessment and Plan List all active problems, but prioritize the

differential diagnosis specific for the patient

Support or disprove the differential with pertinent data (history, physical, labs.)

Incorporate medical literature specific to the patient

Demonstrate thought processes for the diagnostic plan and the treatment plan

Sample CaseCC: Increasing shortness of breath for one weekHPI: The patient is a 60 y.o. man with a history of COPD who has noted increasing SOB over the past week. He used to be able to walk 2 blocks without stopping, but this decreased to 1 block, and now about 20 feet, even sometimes getting winded in his apartment. His inhaler is no longer providing adequate relief, and he uses it now every 2-3 hours. He usually sleeps on 2 pillows, but now notes he needs 3-4. He denies PND. He has a chronic cough productive of greenish sputum, usually worse in the morning on arising. No hemoptysis. He has also noted a new onset of some anterior chest pressure over the past week with exertion (walking, climbing front steps), relieved by rest after 30 seconds. He denies edema or palpitations.

Sample Case (cont.)Past Med. Hist.: COPD diagnosed 5 years before,

currently on meds. Never been hospitalized.Denies diabetes, hypertension, cardiac disease.

Past Surg. Hist.: Appendectomy age 23, WMC

Fam. Hist.: Both parents died of “heart attacks” in their 60s. One younger brother, age 55, just

had a “heart attack”. 2 children in their 30s, alive and well.

Sample Case (cont.)Medications.: Alupent inhaler, 2 puffs qid PRN

Pulmocort 2 puffs bid ASA 81 mg qd

Allergies: NoneSoc. Hist.: Born in NY; no recent outside travel

Former construction worker, retired on disability 4 years ago

Married, lives with wife, pet dogHabits: Smoked 2 packs/day for 30 years, stopped 5

years ago. Drinks 3-4 beers on weekends. Denies other drug use.

Sample Case (cont.)ROS:

Gen: No fevers, chills, appetite or weight changes Skin: No rashes HEENT: Denies trauma, visual or hearing changes Neck: No stiffness or masses Cardio-Resp.: See HPI GI: Occasional epigastric pain awakening him at night, relieved by Maalox. No nausea/vomiting. No diarrhea or constipation, but notes that stools have been occasionally “black” for about 10 days GU: No urgency, frequency, dysuria, nocturia, discharge Extrem: No cramping, muscle or joint pains, swelling Neuro: No headaches, seizures, weakness, paresthesias

Sample Case (cont.)PE: Well dev., well nourished man, appearing his stated age, in

mild resp. distress. BP=150/90, P=92, reg., R=20, T=99.8Head: No evid. of trauma. No sinus tenderness EENT: Conjunc. pale, no icterus. PERRLA, EOMs intact. Fundi not well visualized. Neck: No masses or thyromegaly Chest: Barrel chested, with poor diaphragmatic excursion. Hyperresonant bilaterally. Diminished breath sounds bilaterally, with fine crackles at the right base. No wheezes or rhonchi. Heart: RRR, no murmurs, rubs or gallops. Abd: Bowel sounds active. Soft, with mild epigastric tend. to deep palp. No guarding or rebound. No liver or spleen palp.

Sample Case (cont.)Rectal: Normal sphincter tone. Prostate 2+ without nodules. No

masses. Dark brown stool, heme+. Ext: Bilat. trace edema of ankles. No clubbing or cyanosis. Neuro: A & O x3. Cr. Nerves II-XII intact. Motor strength 5/5

bilaterally. Normal light touch and pinprick sensation. DTRs 2+ and symmetrical.

Labs & Ancillary Data: CBC: Hct=24/WBC=6,700/Plat=210K

Chem: Normal Card.Enzymes: Normal Portable CXR: Incr. markings bilat. Diaphragms low- lying. Heart not increased in size. No infiltrates or effusion. EKG: Sinus rhythm. Axis+60. Prominent P-waves in II, III, aVF. No acute S-T changes.

Sample Case (cont.) – A/PAssessment/Plan:1. COPD exacerbation - - prob. cause of incr. SOB, but

should rule out precipitating factors such as pneumonia, or possible superimposed CHF. Phys.exam shows low-grade fever and rales at the right base. Portable CXR is consistent with COPD, but without definite infiltrate, and WBC is normal.

Plan: Repeat CXR with P-A/lat. views Culture sputum

Consider PFTs Hold antibiotics for now Nebulizer treatments PRN Hold steroids for now in view of poss.GI bleeding

Sample Case (cont.) – A/P

2. Chest pain - - must rule out cardiac disease, but may also be related to COPD exacerbation. No murmurs or gallops on cardiac exam, and cardiac enzymes thus far normal. EKG does not show acute changes.. Plan: Serial EKGs and enzymes Check lipids Pharmacologic stress test

Echo to rule out CHF Diuretics if CHF present

Consider ACE inhib. and starting a statin Hold off on B-blocker in view of COPD

Sample Case (cont.) – A/P3. GI bleeding - - melena by history, epigastric tend. and heme+

stool on exam. Hct=24. Likely UGI source. COPD and related stresses increase the risk of gastritis and/or PUD, and the related anemia may cause both increasing SOB and cardiac ischemic symptoms. Plan: EGD to look for source of bleeding Transfuse up to Hct of 30 in view of chest pain and SOB symptoms Check stool for occult blood Start Nexium 40mg PO bid 4. Hypertension - - BP=150/90, with no prior history. May be related to acute stress, but will need to follow, as this would be a significant factor for cardiac and cerebrovasc. disease. No S4 gallop, and no evidence of LVH on EKG. Plan: Follow BP Consider starting ACE inhibitor, for both BP and cardiac ischemia

Progress Notes

S - - Subjective (patient’s symptoms)

O - - Objective (current physical exam, labs.)

A - - Assessment (updated evaluation of the problem)

P - - Plan (updated diagnostic or therapeutic plan)

For each active problem:

– Information from the patient (symptoms, interval history, changes)

– Information from others (nurses, notes from coverage staff, etc.)

Subjective

– Current observations

– Vital signs and new focused physical exam

– Updated lab data

– Updated information on procedures done since last visit with patient

Objective

– For each problem, indicate if the patient is better, worse, or unchanged

– Has a previously suspected diagnosis been ruled in or out?

– Do the current results (phys. exam, labs, etc.) indicate a new problem?

Assessment

Indicate:– New tests to be ordered that day

– Procedures that need to be done

– Medications, with additions or changes

– Probable discharge plan/goals

Plan

Sample Case – Progress Note

S. Patient is less SOB today following 3 neb. treatments. Ambulating with minimal SOB and no chest pain. Cough persists, prod. greenish sputum.

He has no further abdominal pain. Denies nausea or vomiting. Had a light brown stool this AM,

tested for occult blood.

No other systemic complaints.

Sample Case – Progress Note (cont.)O. Appears comfortable, in no distress.

BP = 130/75, P = 78, regular R= 18, T= 97.8 Neck: No jugular venous distention Chest: Hyperresonant bilaterally with diminished

breath sounds. Fine crackles persist at right base. No wheezes or rhonchi.

Heart: RRR, no murmurs or gallops. Abd: Bowel sounds active. Moderate epigastric

tenderness to deep palpation, without guarding or rebound. No organomegaly.

Ext. No edema.

Sample Case – Progress Note (cont.)O. (continued)

Labs: Stool tested for occult blood - - positive.

CBC: Hct=31 (after 2 units), WBC=11,100

Lipids: Chol.=245/HDL=47/LDL=162

Cardiac enzymes: Negative troponins and CK-MB

Chest P-A/lat.: Small infiltrate at right base

EKG: No change from last tracing

Sample Case – Progress Note (cont.)

A. 1. SOB - - Pneumonia likely by physical exam and CXR. Elevated WBC.

2. Chest pain - - stable currently. Myocardial infarction not likely but underlying CAD still a possibility. Cholesterol elevated.

3. GI bleed - - stool remains positive. UGI source most likely, especially gastritis or PUD.

4. Hypertension - - no longer present. Admission BP likely related to acute stress.

Sample Case – Progress Note (cont.)P. SOB

1. Continue nebulizer treatments.2. Start IV antibiotics for pneumonia

Chest pain / hypercholesterolemia1. Echo scheduled for this PM2. Stress test to be done tomorrow3. Start atorvastatin 10mg daily

GI bleed (gastritis/PUD)1. Continue Nexium2. GI service to see pt. today, for EGD tomorrow AM.

Hypertension on admission 1. Observe for now

Oral PresentationsMany types (depending on service):

• Attending/Preceptor Rounds - - 10 to 15 minutes (comprehensive)

• Condensed bedside rounds - - 2 to 3 minutes (focused on current active problems)

• Quick follow-up - - 2 to 3 minutes (problem oriented)

• Clinic - - problem oriented (there may not be a “chief complaint” per se)

Ask beforehand what is expected

OralPresentations (comprehensive)Similar content to written notes:

• HPI should be all inclusive, all positives and negatives• Still indicate all medications• PMH, FH, SH can be condensed to only positives and

pertinent negatives• Physical exam should be complete - - put the listener

at the bedside• Only indicate pertinent labs (positives and

negatives) that play a role in your differential diagnosis • A summary is extremely helpful - - will refresh the

listener’s memory and demonstrate your grasp of the case

Oral Presentations – more “SOAP”1. Style

- Speed and tone (do not read!)- Smooth, persuasive and confident

2. Organization- Use standard format and order- Present logically and chronologically

3. Argument- Accurate information- Build a case based on sound clinical reasoning- “Sell” your case

4. Pertinence- Include all relevant information- Exclude irrelevant and extraneous data

Oral PresentationsAdvice:• Tell the story - - do not read directly from your write-up• Answer questions and resume from where you left off

• Be honest - - do not improvise if you are not certain of data

• Be complete and accurate - - remember that the listener is composing a prioritized differential diagnosis based upon your information

• Practice! - - the more you do, the better you will get