Jacobi Ambulatory Care Service Why Write Outpatient Notes? Susan Dresdner, M.D. Eleanor Weinstein, M.D.

Jacobi Ambulatory Care Service Why Write Notes? The Positive Reasons Communication –Other MD’s (consultants, interim visits, ED) –Professional staff (nurses, social workers, dieticians)

Jacobi Ambulatory Care Service Why Write Notes? The Positive Reasons Organization: highlights abnormals, helps keep thoughts clear Record-keeping: keep track of each diagnosis, follow symptoms, prior drug/antibiotic use Memory cues Clarify intent/ thought process Interpretation

Jacobi Ambulatory Care Service Why Write Notes? The Negative Reasons Medico-legal: chart is legal document Evidence of events and intentions Billing Document supervision

Jacobi Ambulatory Care Service As Many Occasions for Writing Notes As There Are For Seeing Patients Outpatient Notes Routine clinic visit Walk-In Medical consultation Other contact (phone call, etc.) Procedure Inpatient Notes The Admission Note The Daily Progress Note The Coverage Note The Procedure Note The Transfer Note The Code Note The Death Note

Jacobi Ambulatory Care Service Routine Ambulatory Care Visit Note All notes are written in the computer Who gave history? Who is present? Was interpreter used (use language line for all translation and document interpreter ID)? Must obtain Social History! Address adherence Assessment = Differential Diagnosis. THINK! Clear management plan

Jacobi Ambulatory Care Service

Jacobi Ambulatory Care Service Routine Visit Notes: “SOAP” Notes S ubjective O bjective A ssessment P lan

Jacobi Ambulatory Care Service “Subjective” In the patient’s own words: –What does patient tell you about how he is feeling? –How is the disease process affecting the patient?

Jacobi Ambulatory Care Service “Objective” How do you perceive the patient –appearance –physical exam (it is NOT okay to say “PE unchanged!) –Document BP’s in separate field –laboratory data –medication

Jacobi Ambulatory Care Service “Assessment” The MOST IMPORTANT part of the note, usually given the least attention Summary of the situation How do you put all of the information together? –Analysis of all of the data including consultant opinions –Address all abnormal exam and lab findings Organize by organ system or problem What do you THINK?

Jacobi Ambulatory Care Service “Plan” How are you going to handle each of the identified problems?

Jacobi Ambulatory Care Service Acknowledge and address all labs since last visit, no need to copy all labs over Acknowledge all notes from consultants Must have “Healthcare Maintenance” section in plan End note with “Case discussed with Dr. _______”

Jacobi Ambulatory Care Service A Sample Progress Note

Jacobi Ambulatory Care Service A Sample Progress Note, con’t

Jacobi Ambulatory Care Service Procedure Notes What procedure? What indication? Begin with “after informed consent was obtained….” Describe procedure in detail “Pt. tolerated procedure well” Any necessary f/u tests Who supervised

Jacobi Ambulatory Care Service Transfer Notes (to ER, Psych ER) No patient may be transferred without full note in the computer! Must discuss reason for transfer and plan Notify accepting service and acknowledge this in note

Jacobi Ambulatory Care Service Consultation Notes Indicate reason for consultation Full history and physical exam Assessment of situation and recommendations Plans for further evaluation

Jacobi Ambulatory Care Service Ten Commandments of Outpatient Note Writing Write coherently Do not write “scrolling notes” Acknowledge all other notes before yours Acknowledge data Document all pt. encounters Analyze Plan Document healthcare maintenance Remember your attending who discussed the case Do not wage war in chart

Jacobi Ambulatory Care Service