How do U Write A
Note?
Omar S. Darwish, MS, DO
Hospitalist, Assistant Professor of Medicine
Department of Medicine
October 9, 2014
S
Objectives
S To learn How to Write the Key Elements of Writing a History and
Physical/Admission Note
S To know common misconceptions of writing a progress note
S To learn how to make your note have “purpose”
S To learn how to Write a Concise and Valued Discharge Note
Why is it Important?
S A way to communicate with specialist, nurses, speech/physical
therapy, case managers, or anyone who is involved in the care of
the patient.
S Appropriate utilization review and quality of care evaluations.
S Collection of data that may be used for research and education.
S Accurate and timely claims review and payment.
Common Misconceptions
S The More I document, the More Money the Hospital gets
reimbursed; therefore, every problem and every organ on my
exam needs to be documented
S Anyone who reads my last progress note should be able to know
everything about the patient’s past history and every event and
lab that has already been ordered during a hospitalization so
that the person doesn’t have to look at prior notes.
Writing a Note Just to please?
S Writing a note just to please someone else
S Examples include
S
Giving the trend of Hemoglobin
S
Given a long explanation of why something isn’t when it is
obvious. Example: This is less likely PE given that the patient is
not tachycardic, D-Dimer is normal, their oxygenation is normal,
and they are not short of the breath and the CT angio is negative.
(An exaggeration, but you get my point)
S
Giving the definition of Sepsis. this happens a lot!!! Please stop.
History and Physical
S Research has shown that physicians make the diagnosis
from the patient’s history in 70-90% of cases.
S With a good history, exam, and preliminary date obtained
from ER physicians, medicine residents should be able to
formulate and therefore write a good assessment/plan
S A lot of the history has to do with asking the right questions
and forming it in a way that the patient can understand.
An example
S 55 year old man with past history of lung cancer, coronary
artery disease, COPD, hypothyroidism presents with
progressive worsening of shortness of breath for 2 days. He
admits to having a cough and wheezing, but no
fevers/chills. No chest pain.
S What is the most likely cause?
Better Way
S
55 yo man presents with shortness of breath x 2 days. At baseline has SOB with
exertion but he says now it is happening while at rest. He said 2 days ago while
watching TV he felt a sudden onset of SOB and broke out in a sweat. He denied
any fevers/chills. He says he has a cough and some wheezing but this hasn’t
changed for the past 2 years.
S
The patient has a history of lung cancer diagnosed 2 years ago and his last
chemotherapy was 2 weeks ago. He denies any recent surgeries, calf pain, or history
of DVT or PE.
S
Patient has a history of MI 2006 with 2 stents placed in the LAD and is taking
Aspirin 81, Coreg 6.25 bid, and simvastatin 20 mg po qday.
S
ER course: afebrile, HR 94, BP 110/67, O2 sat 95% on RA, RR 22. patient had an
CXR which showed hyperinflated lung fields. He was given Solumedrol and
Ceftriaxone/Azithromycin, blood cultures were drawn.
Other parts of the History
S Patient here for abdominal pain:
S You document: Family history: mother died at 87 from
myocardial infarction. (Even if the patient was here for chest
pain, this family history isn’t significant)
S Better: No history of GI cancers.
S Social History: Important: Allows you to connect with your
patient. Ask in a way they have never been asked. So this is more
for you to understand who your patient is: e.g. works at a bakery,
married with 3 children, doesn’t use illicit drugs.
Assessment/Plan on Admission
Note
Do’s and Don’ts of Writing an Assessment/Plan on Admission
S
Don’t give a 1 paragraph past medical history and then state the problems.
Your reader can read the past medical history that you wrote above.
S
Don’t use the word “Consider” or state that you are going to do something if
something happens. E.g. If patient is unstable, will send to ICU. Avoid
nephrotoxins, consider increasing Metoprolol, Replete Lytes when needed
S
Do give level of severity of symptom or diagnostic lab value SO use
“adjectives” E.g. Severe DKA, Severe, life-threatening hypokalemia. This
tells the reader that you have identified their severity of illness. Of course you
need to have medical knowledge; so ask!
S
Do assess your DVT risk as Low, Intermediate and High and if not on
anticoagulation give reasons why.
Assessment/Plan
S Be careful what you write
S Best example: Chest Pain.
S If you use the word “atypical” you are telling your audience that the
chest pain is cardiac in origin. So, if you meant to say that its
noncardiac, then write just that.
S By advice to you is that if a patient comes in with chest pain to write
down if you are concerned that it is cardiac or not. Particularly if they
don’t have a history of cardiac disease. Stay away from words like stable
or unstable angina.
A patient who presents to you for the first
time with so called “stable” angina is not so stable. If you use the words
unstable angina, then the patient needs to be on heparin gtt or Lovenox.
S So, I recommend that you write: Acute Chest Pain, concerned its cardiac
in origin: given troponins are normal, will order a stress test tomorrow
morning.
Progress Note:
Have Purpose
S What do I mean?
S Don’t right a note just for the sake of writing a note
The note should reflect WHAT YOU DID THAT DAY AND
ONLY THAT DAY!!!
4 Areas
S Subjective
S Exam
S Date
S Assessment/Plan
Subjective
S
Please Do not Write
S “No Events Overnight” You
Mean nothing bad happened?
S
Did you tell your reader
anything by writing this
statement?
S
Focus on
S Patient’s Chief Complaint
S Patient’s Pain, eating, bowel
movements, ambulation,
sleep
S Use comparative words
(more, less, better, worse)
Patient’s Are Concerned about
their Pain
S Subjective
S Always ask a patient if they have pain and have them rate the
score.
Subjective: Don’t Write…
S This is not where you record that the patient didn’t like her
meal or the TV didn’t work, etc.
S It is also not where you record lab findings or study results
that returned overnight.
Exam
S Everyone has a template
S Please Use It, but on your first progress note make it “real”
S Regardless of the medical problem, some doctors like the
heart, lungs, and abdomen examined on every patient. You
won’t be wrong to do this but it is not always necessary.
Exam
Robot
Real
S
Gen: NAD, alert and oriented x 3
S
Vitals: BP 120/80, HR 80, RR 14, O2 SAT 99
S
S
Comfortable, sitting up in bed
S
Vitals: BP 120/80, HR 80, RR 14, O2 SAT 99
S
CTAB and Breathing comfortably
S
RRR
S
Abd: soft, ND, less tender epigastric area
S
Ext: no edema, R peripheral line, no signs of
infection
S
GU: foley catheter, clear urine in foley bag
HEENT: NC/AT, PERRLA, EOMI
S
CV: RRR no m/r/g
S
Lungs: CTAB, no wheezing/rales/rhonchi
S
Abdomen: mild TTP, ND,
S
Ext: no edema, no cyanosis
S
Neuro: no focal deficits
S
Skin: no rashes
Data
S Don’t Cut and Paste Imaging findings and echo reports
S When you summarize, it tells the reader that you reviewed the
report and put thought behind it. Cutting and pasting data does
not show that you understood the report.
S Keeps the note clean/not so busy. People want to know your
thoughts; if they want the report, they can go to the report
section.
S Don’t worry you are not going to make a mistake if you
summarize
Assessment/Plan for Progress
Note
S Probably the Most difficult Part of the Note for a Student,
Intern, and Resident
Assessment/Plan, Progress Note
The Formula
S The formula:
S Symptom/Diagnosis, (IMPROVING,
WORSENING, OR UNCHANGED)
S If a Symptom, follow it with a differential diagnosis
(dd).
S The number of dd varies
S Your plan should include workup to support or
exclude a dd
Choose One…
S A. Acute Dyspnea-improving, Differential ischemic heart
disease and less likely PE. Will get troponins.
S B. Acute Dyspnea most likely anxiety attack-no change, but
concerned for ischemic heart disease and Pulmonary
embolism based on risk factors.
S start Ativan 1 mg q6, check troponins and get a CT angio
Must Know the
Terminology/Definitions
S
DON’T WRITE THIS
S Altered Mental Status
S Delirium if an identifiable cause is
known e.g. infection, drug
S CHF
S Respiratory Distress
S SIRS
S Malnourished,
S Hypertensive Urgency/Emergency
S
THIS IS BETTER
S Encepalopathy
S Acute on Chronic Systolic Heart
Failure, Acute Systolic heart
Failure, Acute diastolic HF
S Acute Hypoxic Respiratory
failure, Acute Hypercapneic
Respiratory Failure
S Sepsis, Pancreatitis at least give a
differential when writing SIRS.
S Protein –Calorie Malnutiriton,
Mild-Severe
S Accelerated or Malignant
Hypertension
What about Delirium?
S From the Coding world, Delirium is a mental disorder or a
symptom.
S Encephalopathy is defined as a neurological diagnosis that can be
further classified as toxic or metabolic
S Therefore, the term delirium is best reserved for psychiatric
conditions unrelated to underlying systemic conditions.
S So if your patient becomes delirious overnight and you identify an
infection. You should write: Sepsis encephalopathy and if not
septic, write down Metabolic Encephalopathy 2nd UTI.
Encephalopathy
S
Toxic encephalopathy
S Drugs, e.g. Alcohol
S Toxins/poisons
S Medications (e.g. Dilantin overdose)
S
Metabolic Encephalopathy
S Fever
S Dehydration
S Electrolyte imbalance
S Acidosis
S Infection (septic
encephalopathy)
S Organ failure (Uremia and
Hepatic)
Hypertension – Don’t get upset
S The Coding world doesn’t recognize hypertensive urgency and emergency
or hypertensive crisis. These terms will be classified as a non-specific or
benign hypertension code having virtually no clinical significance.
S Archaic terms such as accelerated and malignant are used in the coding
world and they simply haven’t caught up with us.
S Solution: Hypertensive Urgency due to Accelerated HTN or
Hypertensive Urgency/Accelerated HTN; Hypertensive Emergency due to
Malignant HTN or Hypertensive Emergency/Malignant HTN
Protein-Calorie Malnutrition
S Why is it important to Identify protein-calorie malnutrition
S Signifies a higher mortality, therefore denotes severity of illness
S With such a severity of illness identified this typically means
that a lot of time and effort was needed by YOU to care for
such an individual
Malnutrition related ICD-9 codes
ICD-9 codes related to
nutrition
S
260 Kwashiorkor
S
261 Nutritional Marasmus
S
262 Other Severe Protein-Calorie
Malnutrition
S
263.0 Malnutrition of Moderate
Degree
S
263.1 Malnutrition of Mild Degree
S
263.8 Other Protein-Calorie
Malnutrition
S
263.9 Unspecified Protein-Calorie
Malnutrition
S
278.1 Morbid Obesity
S
799.4 Cachexia
Type of Comorbidity associated
with ICD-9
S
MCC
S
MCC
S
MCC
S
None
S
None
S
CC
S
CC
S
None
S
CC
Coding Needs To
Reflect the Severity of
Illness of a Patient
It’s Important to State
Why the Patient has
Such a Diagnosis,
e.g. Malignancy,
AIDS, Chronic
Disease such as
COPD, CHF. A plan
does not necessarily
need to be
documented.
I can’t breathe…
Don’t Write “Respiratory
Distress”
S Non-specific terms that do not reflect any significant
respiratory problem
S Hypoxia
S Severe dyspnea
S Respiratory insufficiency
S Respiratory distress
I can’t breathe…
Write this…
S Acute Respiratory Failure
S pO2 <60 mm Hg (GOLD STANDARD) or SpO2 (pulse
oximetry) <91% breathing room air
S pCO2 >50 and pH <7.35
S P/F ratio (pO2 / FIO2) <300
S pO2 decrease or pCO2 increase by 10 mm Hg from baseline (if
known)
Acute Hypoxic Respiratory Failure
Acute Hypercapnaic Respiratory Failure
Acute on Chronic Hypercapnaic Respiratory Failure
Patients on Home Oxygen should be identified as Chronic Hypoxic Respiratory
Failure
An example
S 55 year old with hypothyroidism, diabetes, and HTN
admitted NEW acute heart failure
S What should my A/P be on the progress note say?
S Do I need to mention all the medical problems?
It depends…
S Acute Heart Failure of Unknown type – improving,
Differential includes HTN or new ischemia
Continue with Lasix 20 mg IV bid
S Await echocardiogram results
S
Diabetes, HTN, and hypothyroidism are all chronic conditions and of
those diabetes and HTN are conditions that should be mentioned
particularly at the beginning of a hospitalization. From my
experience, most patients are in the hospital for 3-4 days and so such
conditions should be documented during the first 3-4 days. If other
acute conditions start occurring and HTN and diabetes are controlled
then these conditions do not need to be mentioned everyday.
S Hypertension with heart disease – controlled
S Continue with Lisinopril 20 mg po qday
S Type II Diabetes with peripheral neuropathy – inpatient
sugar goals are met
S Continue with Lantus 20 units qHS and Neurontin 100 mg po
TID.
Prophylaxis
S Don’t Just Write: DVT/GI prophylaxis on heparin
Surgeon General’s Call to Action to
Prevent DVT and PE 2008
S Annual incidence VTE 350,000-600,000/year (underestimate?)1,2
S 28,000 pts/year die of VTE3 (underestimate?)
S 30% die after 3 months4  100,000-180,000 die/year
S More deaths than breast cancer, MVAs, and AIDS combined
S Most are hospital related
S Significant cost and morbidity (recurrent DVT/PE, post-thrombotic
syndrome)
1. Silverstein MD, Heit JA, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ, 3rd. Trends in the incidence of deep vein thrombosis and
pulmonary embolism: a 25-year population-based study. Arch Intern Med 1998;158(6):585-93.
2. U.S. Census Bureau News. Nation’s Population to reach 300 Million on Oct. 17. U.S. Department of Commerce Public Information Office.
October 12, 2006. Available at: http://www.census.gov/Press-Release/www/.
3. Horlander KT, Mannino DM, Leeper KV. Pulmonary embolism mortality in the United States, 1979-1998: an analysis using multiple-cause
mortality data. Arch Intern Med 2003;163(14):1711-7.
4. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ, 3rd. Predictors of survival after deep vein thrombosis and
pulmonary embolism: a population-based, cohort study. Arch Intern Med 1999;159(5):445-53.
UCI GOALS
FY 2013 Organizational Goals
1. Reduce pressure ulcers to below the CALNOC mean (pressure ulcers /
patients observed)
2. Improve Care of Patients with Severe Sepsis – Increase the percentage of
patients who receive antibiotics in appropriate time frame to 60%
3. Achieve an Average Length of Stay (excluding Psych) of 5.7
Surgical Care Improvement Project
(SCIP)
S Currently for surgical patients there are 2 measures that are
being assessed:
1. Ordering of thromboprophylaxis
2. Receiving treatment within 24 Hours Prior
to Surgery to 24-72 Hours After Surgery.
2005 Medi-Cal Hospital Waiver
S First off, does it matter? At times we are the primary
patients for surgical patients and so making sure patients are
on VTE prophylaxis is on us as well
S On the medical side, the financing of Medi-Cal payments to
hospitals will be based on OUR PERFORMANCE
measures that we set
S VTE makes up a component of the 17 billion dollars that
we can receive!
UCIMC VTE Risk Assessment & Treatment Algorithm
Risk Factors for VTE
Age > 40
Chemo/XRT ± Cancer
Major surgery
BMI ≥ 30
High estrogen state
Prior VTE
Immobile
IBD
Trauma
Heart Failure
Clotting disorder
OCP
Spinal Cord Injury
Smoking
Venous Stasis
Paralysis
Pregnancy
At an outside hospital for >2 days
prior to transfer to UCI
Acute illness (CVA, infection)
Erythropoiesis stimulant use
Central Line or PICC use
Low Risk
•Characteristics
• Age <40, BMI<30 and no
risk factors OR
•Ambulatory patient with
low risk surgery and length
of stay <1day OR
•Pregnant patient without
hypercoaguable state
•Treatment
•Treat with early and
aggressive ambulation TID
Moderate Risk
•Characteristics
•Medical/Surgical patient
with at least 1 risk factor
and length of stay ≥1 day
•Treatment
•Pharmacological ±
SCDs
High Risk
•Characteristics
•One or more medical risk
factor and high risk surgery
(THA, hip
hemiarthroplasty, TKA,
Hip/pelvis/lower extremity
fracture, major multiple
trauma, acute spinal injury
with paresis,
abdominal/pelvic cancer
surgery
•Treatment
•Pharmacological & SCDs
GI Prophylaxis
ASHP guidelines
American Society of Health-System Pharmacists
Most Patients on the WARDS DO NOT NEED GI PROPHYLAXIS
If you are curious…
S Progress Notes
S Have 3 Levels of Coding
S To Get to Level 3 in a progress note INPATIENT you must
meet the following:
S
2 out 3 of the following
S Detailed History (C/C with 4 HPI elements, min 2 ROS)
S Detailed Exam (12 bullets)
S High Complexity Medical Decision Making
Decision Making
S Broken down into
S Problem Points
S Data Points
S Level of Risk
Problem Points
Data Points
Level of Risk, e.g High Risk
Assess Decision Making for
Each of These…
S
A/P
S
A/P
Acute Renal Failure 2nd Dehydration
Diabetes stable, RISS
--IV fluids at 125 ml/h
Hypertension, stable, continue c
Norvasc
--check UA, order renal ultrasound
--check Chem 7 tomorrow
Hyperlipidemia, stable, continue with
statin
--obtain old records to see pt’s baseline
creatinine.
Hypothyroidism, stable, continue c
meds
Discharge Summary
S Make sure you state severity of illness in discharge summary,
Protein calorie malnutrition, hyponatremia
S Don’t tell anyone what happened in the middle… Just tell them
the beginning and the end.
S Your goal is to make the transition between inpatient to
ambulatory setting or other facility smooth.
S Have a separate section that gives a patient Discharge Instructions.
Sample
S HPI: xxxxxxxxxxxxxx
S Discharge Diagnosis:
Acute Renal Failure 2nd dehydration form diarrhea
S Acute Diarrhea 2nd C. diff
S Hyponatremia Hypovolemia 2nd diarrhea
S Type II Diabetes c peripheral neuropathy
S
Hospital Course: 55 yo man presented with acute diarrhea and fond to have acute renal
failure with creatinine of 3. C.diff was + and patient started on Flagyl with clinical
improvement and IV hydration improved creatinine to 1.3.
Discharge Instructions: -Patient to take Flagyl 500 tid for 10 days
- Drink 1.5-2.0 Liters of water/day
-f/u with Dr. X to see if Flagyl needs to be continued further
and continue working on achieving better blood sugar control
Conclusion
S Have Purpose when writing your notes
S Your Note actually Defines You in terms of how you
approach your patient and your clinical reasoning