1. Basics of Writing Notes

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

3. 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

4. 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 !

5. History and Physical (Admission note)

6. 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

7. 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

8. 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

9. 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

10. 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 ……

11. 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

12. 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.

13. 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

14. 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

15. 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

16. 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 !

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

18. 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

19. 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

20. 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

21. Progress Note aka the “SOAP” Note

22. 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

23. 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

24. 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)

25. 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 ….

26. 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

27. Discharge Summary

28. 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

29. 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 …

30. Pre-Operative and Operative notes

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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?

43. 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?

44. Any Questions ??

45. References
Maxwell Quick Reference Book