Basics of Writing Notes

Outline The Patient Chart Admission Note (History and Physical) Progress Notes Discharge Notes Operative Notes Pre and post-operative Procedure notes www.pptbackgrounds.net

The Patient Chart Chart is located at the patient bedside, electronically or at nursing station Essential components of the chart Admission notes, physicians Orders, administered medications, vitals, progress notes, laboratory and radiographic examinations and discharge summary

The Patient Chart Important medical and legal document Need to write legibly and sign your notes !! Everything you write must be co-signed by and attending physician or by your senior resident ! Always date, time and sign your notes !

History and Physical (Admission note)

The History and Physical (H+P) Initial note for a patient admitted to the hospital Summarizes: Why the patient came to the hospital Medical history prior to this admission Initial physical exam to include initial labs/studies Gives the physician the opportunity to formulate a differential diagnosis and treatment plan

The History + Physical (H+P) Tips Always welcome the patient – ensure comfort and privacy Know the patient’s name Introduce and identify yourself Set the agenda for the questioning

H+P Components Chief complaint History of Present Illness Past Medical History Past Surgical History Allergies Medications Social History Family History Review of Systems Physical Exam Labs/Studies Assessment and Plan

Chief Complaint (CC) This is why the patient is in the Emergency Room or in the office seeing you “This is in the patients own words” Examples: Shortness of breath Chest pain Nausea and Vomiting

History of Present Illness (HPI) Detailed reason why patient is here Use the OPQRSTA approach to cover information Begin by listing all the relevant major medical problems in first sentence Mr. Morris with history of hypertension, diabetes, obstructive sleep apnea and osteoarthritis presented to the hospital with ……

OPQRSTA Approach Onset: Prior occurrences Progression Quality When did the CC occur Prior occurrences Progression Is it getting worse or better? What makes it better or worse Quality Is there pain, and if so how would you describe it? Radiation of Symptoms Scale On scale of 1-10, how bad are the symptoms Timing When do they occur? Associated symptoms Any other symptoms not already covered

HPI Continued Include in this section a brief synopsis of what was done in the ER or at an outside hospital Example: 50 year old male with hypertension, diabetes, obstructive sleep apnea and osteoarthritis presented to the hospital complaining of fevers, chills and a cough for the past week. The cough started approximately one week ago, was productive in nature, and had an occasional blood tinge to it. The patient says that the fever and chills began two days ago and has prevented him from sleeping at night. Incidentally, the patient’s brother, who was visiting from Herat, was recently ill with similar symptoms.

Past Medical and Surgical History Major disease(adult and childhood) with brief discussion of duration and treatment Ex: Hypertension x 10 years well controlled on medications, s/p stroke in 1991 with residual left sided weakness Hospitalizations (Reason for admissions, when and where?) Surgical procedures with dates (Indications) Example: Open Cholecystectomy at age 46 Immunizations

Other Components Social history: Occupation Medications: Dosage and duration Does patient take the medications? Over the counter and herbal medications Allergies: Record allergies and reactions to medications, foods and latex No known drug allergies Social history: Occupation Tobacco, alcohol or illicit drug use Marital and children status Family History: Include inherited diseases Ex: + Diabetes in mother and sister

Review of Systems (ROS) Series of questions based on organ system: General/Constitutional Skin/Breast Eyes/Ears/Nose/Mouth/Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Neurologic/Psychiatric It is acceptable to write: ROS as per HPI, otherwise negative - It is acceptable to write: ROS as per HPI, otherwise negative

You must do a Physical Examination !!! General (Always include vital signs) HEENT (Head, eyes, ears, nose, throat) Heart Lungs Abdomen Extremities Skin Neurology You must do a Physical Examination !!! Need to develop a systematic approach for doing the physical examination !

Labs and Radiographic Studies Admission labs and important studies Example: Complete blood count Chemistry panel Cardiac enzymes EKG Chest X-ray

Assessment and Plan Assessment of the patient: This is what you think is wrong with the patient Start with a short summary of 3-4 sentences maximum Follow by listing each active problem numerically with most important first

Assessment and Plan Assessment of the patient: Plan: Each problem you list requires an in depth assessment which includes a differential diagnosis Support your thoughts with elements of the patient’s history, physical, lab results Plan: Conclude with a detailed treatment plan Sign your note with resident year and phone number

Example Assessment: The patient is a 50 year old male with hypertension, diabetes, and obstructive sleep apnea who presents to the hospital with a respiratory infection. Plan: The differential diagnosis includes bacterial pneumonia, tuberculosis, viral pneumonia, or less likely pulmonary sarcoid. 1. Pulmonary Infection: - Obtain blood cultures x 3 - Obtain sputum cultures and smear x 3 - Start appropriate antibiotics for community acquired pneumonia - Initiate primary tuberculosis treatment - Admit to hospital with appropriate isolation precautions: respiratory and droplet precautions 2. Hypertension: - Continue outpatient medications   3. Diabetes: - Continue outpatient diabetic medications - Institute an insulin sliding scale

Progress Note aka the “SOAP” Note www.maxwellbook.com

Progress (SOAP) Notes Every inpatient should have a daily progress note in the chart This note allows you to: Communicate your thoughts about a patient’s condition Your treatment plan And any progress that has been made over the past 24 hours

S= Subjective Summarizes how the patient feels Includes pertinent events that occurred overnight Look through nursing notes or ask the nurse about how the patient did overnight

O=Objective Objective information including: Vital signs Temperature, blood pressure, heart rate, respiratory rate, oxygen saturation and pain scale I/O (“Ins and Outs”) Pertinent physical exam findings More recent labs and diagnostic test results Current inpatient medications (include # of days on the medication. For example, Gentamicin (7/14)

A= Assessment 1-2 sentence summary of the prior two sections which includes: Patient’s age, hospital day (if surgical patient include post-op day), and disease process For example: 50 year old male admitted with heart failure …. 50 year old male post-op day # 3 status post appendectomy ….

P= Plan This section includes: What you plan to accomplish over the next 24 hours including medications, procedures, consults, or discharges Again, always sign your notes and provide a contact phone number

Discharge Summary www.nexthospital.com

Discharge Summary Provides the patient and their outpatient physicians with: Brief summary of the patient’s presentation to the hospital The hospital course And any further treatment recommendations

Discharge Summary Important Components of a Discharge Summary (see attached example): List the number one problem for the patient’s admission List important admission labs, vitals, signs + symptoms of the patient Diagnostic work done during the patient’s admission You can write in the discharge summary if there is any work-up that is still pending at discharge Need to write down who the patient is to follow-up with …

Pre-Operative and Operative notes www.heart-valve-surgery.com

Pre-Operative Note These notes are written on all surgical patients This is essentially a checklist to confirm all the required pre-op information has been collected and patient is ready for surgery This should be completed in the progress note section prior to surgery

Pre-Operative Note Format Date and time Pre-op diagnosis: Appendicitis Procedure: Open Appendectomy Pre-op Orders: Nothing Per Oral (NPO) Labs: CBC, PT/PTT (record results prior to the procedure) CXR: No active disease (note the findings) EKG: Normal sinus rhythm (note any abnormalities) Blood: Typed and crossed for 2 units of O+ Consent: Singed on chart Anesthesia: To see patient, or patient seen, note on chart

Operative Note Pre-op Diagnosis: Appendicitis Post-Op Diagnosis: Appendicitis Procedure: Appendectomy (what was done?) Surgeons: Attending, resident and students who scrubbed in on the procedure Findings: acutely inflamed appendix

Operative Note Anesthesia: general with endotracheal tube, spinal, local, etc Fluids: amount and type (electrolytes, blood); also record the urine output Estimated blood loss (EBL): amount in cc Drains: List all in the patient after the procedure Number, type and location

Operative Note Hardware: Relevant usually for orthopedics Specimens: Type of specimen sent to pathology Complications: List any complications Needle and sponge count: correct x 2 Disposition: Stable, extubated, transferred to recovery room

Post-Operative Notes Post-op checks are progress notes are usually written 4-8 hrs after completion of case Documents the patient’s immediate post-op condition and progress Use a modified SOAP note

Post-Operative Notes Status post (s/p): Procedure and indication S: Subjective Patient complaints or comments CHECK consciousness (alert, oriented, drowsy), ambulating Taking oral medications Pain control

Post-Operative Note O= Objective Vitals: BP, HR, Respirations, Temp, O2 sat INS/OUTS: IV fluid, PO intake, drains/tubes Exam: Physical findings Incisions/dressings -- clean, dry and intact (CDI) Neurovascular status Meds: Routine or new medications (Antibiotics, DVT prophylaxis) Labs: Results of labs since surgery

Post-Operative Note A/P: Assessment and Plan Patient is stable/unstable/critical status post procedure Include problems and how you plan to address them Plans for diet, ambulation, dressing changes, fluid management, foley, drains, pain management and etc. Don’t forget to sign your name, date and provide a phone number

Procedure Note After performing a procedure: It is imperative that you document procedures performed on patients in the patient’s chart This allows other physicians to know what occurred and can act if a complication should arise later in the day

Procedure Note Format Procedure: What procedure did you do? Permit: Document that you explained and patient understands the procedure Discussed alternatives, risks, and benefits of the procedure to the patient Risks: Bleeding, infection, reaction to anesthesia, general injury, etc) - Document that the patient understands the explanation of the procedure, its alternatives, risks, and benefits and has consented to continue with the procedure

Procedure Note Format Indications: Why did you do the procedure? Physician (s): Who performed the procedure? Description: How did you do the procedure? Where did you do the procedure? What anesthetic did you use?

Procedure Note Format Complications: Did anything go wrong with the procedure, bleeding, pneumothorax, infection? EBL: estimate the amount of blood loss in cc’s Disposition: How did the patient tolerate the procedure? Where will the patient go after the procedure?

Any Questions ??

References Maxwell Quick Reference Book. 2006.