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-opDx: 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: [Link] 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 hours
S: 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 Group 3. Hospital
Progress Note A Progress Note B
Group 2. Procedure Note:
[Link]
watch?
v=R2_0gOI8uV0&featur
e=related
ADMISSION ORDERS: ADCA VAN DIMLS
Admit to service of… Diet
Diagnosis IV orders
Condition Medications
Allergies Labs
Special
Vital Signs
Activity
Nursing
ADMIT
Attending Physicians Name Admit: Dr. Duerfedlt,
Unit/Floor:
Medical Medical Floor
Surgery Notify: Dr. D.O. of
Medical ICU
Surgical ICU patients admission
If the family physician is not the
same as the attending, you can notify
the family doctor as a courtesy.
DIAGNOSIS
List both the diagnosis that
caused the patient to be Diagnosis: Pneumonia
admitted (primary) and any Secondary Diagnoses:
other diagnosis(es) that the Hypertension, DM Type
patient currently carries 2
CONDITION
General condition of patient Condition: Stable
at time of admission Code Status: Full Code
Stable
Guarded
Critical
Code Status
ALLERGIES
Medication, food or Allergies: Penicillin;
environmental allergies anaphylaxis
Be sure to state the reaction
if known
VITALS
Frequency: How often do Vitals: q shift (every 8
you want this patient’s vitals hours)
checked Notify H/O if BP<90/60,
Is the patient’s condition one >160/110; Pulse >110 or
which you may expect a <60; temp>101.5;
change over a short period of UOP<35cc/h for>2hours;
time?
RR>30
Parameters
*H/O = house officer
When should the doctor be
called
ACTIVITY
Restrictions on patients Activity: Bathroom
activity privileges, Fall Precautions
Bed rest
Bedside commode
Up Ad Lib
Bathroom privileges
Ambulation
Up in chair
Up with nurse assistance
Fall precautions
Seizure precautions
Isolation
NURSING
Any special functions that Nursing:
the nurse must carry out and O2 2L via NC titrated to
frequency if applicable maintain sats at or
I/O’s above 95%
Oxygen (some docs put this
other places too)
Continuous pulse oximetry
Pulse oximeter Accuchecks AC and HS
Accu checks Incentive spirometry q 2
Drain and/or catheter hrs while awake
instructions
Incentive spirometry
Wound care
Stool guaiac
DIET
State any dietary restrictions
NPO (nothing per oral)
Diet: 1800 ADA diet
Ice chips only
Clear fluid only
Soft
Full
Thickened liquids
2200 calorie ADA
Cardiac
Low sodium
Low residue
Regular diet
IV
*THIS SECTION IS RESERVED FOR IV FLUID ADMINISTRATION, NOT FOR IV MEDICATIONS*
IV: 0.9 NS KVO
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
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 Blood culture: now
when labs should take place Sputum culture: now
CBC, chem 7: in am
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.
SPECIAL
Are there any special orders Respiratory therapy to
Ancillary services follow
Radiology
Consults
Special preps
ADMISSION ORDERS
Admit to: Dr. D on med-surg floor
Dx: pneumonia
Secondary Diagnoses: HTN, DM type 2
Condition: stable
Allergies: Penicillin- anaphylaxis.
Vitals: q shift (every 8 hours) If temp is
greater than 102° call attending
Activity: Bathroom privileges, fall precautions
Nursing: O 2L via NC titrated to maintain
2
sats at or above 95%. Continuous pulse
oximetry. Accuchecks AC and HS. Incentive
spirometry q 2hrs while awake.
ADMISSION ORDER
Diet: 1800 ADA
Medications
Levaquin IV 650mg qd
IV: 0.9 normal saline to Tylenol 500mg PO q 4-6 hr
KVO prn HA or fever greater than
101
Ambien 10 mg PO @ hs prn
Labs insomnia
Sliding scale coverage of
Blood culture: now
accuchecks using low-dose
Sputum culture: now
algorithm
CBC, chem 7: in am Duo-neb treatments q2hr prn
SOB or wheeze
Special: Respiratory Duo-neb tx q 6hours
therapy to follow Mucinex 600mg PO Q 6hrs
Lisinopril 10 mg PO Q day
NOTE-WRITING RESOURCES
Maxwell Quick Medical Reference
A must-have!!
Only $7.95!!
DO or MDPocket is an alternative but is $25.00
How to be a truly EXCELLENT Junior Medical Student
250 Mistakes 3rd year medical students make
Clinician’s Pocket Reference (Scut Monkey)
[Link]
Medfools also has some sample personal statements
