Clinical Documentation
Amish A Dangodara, MD, FACP
Professor of Medicine
Hospitalist Program
University of California, Irvine
School of Medicine
07.11.14
Need 2 Volunteers:
R1 & R3
Clinical Documentation
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Chief Complaint
HPI: 4+ elements of chief complaint
Past Hx: 3/3
– PMHx
• Medical, Surgical, Psych, OB, etc.
• Allergies, Medications
– FHx
– SHx
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ROS: 9+ systems
Exam: 8+ systems or 2 detailed systems
Data: 2+ elements
Assessment: acute, active, unstable
Plan
Case
Ms. Anne Gina Pektoras is a 56 year old Greek woman who presents with
a chief complaint of abdominal pain and shows you the following list:
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High BP, 1985
High cholesterol, 1989
Diabetes, 1991
Pancreatitis, 1994
Gall bladder surgery, 1994
Liver failure & sepsis, 1994
Tracheostomy & G-tube, 1994,
removed 1995
Blood clot in lung, 1994
Fluid in lung, 2005
Ovarian cancer, 2005, surgery
2006, chemotherapy 2005-2007
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Atenolol 100 mg at night
Fosinopril 20 mg per day, twice
a day
Lasix 20 mg per day
Glyburide 15 mg per day, 2 in
morning, 1 at night
Lipitor 40 mg at night
Multivitamin 1 daily
Calcium/Vitamin D twice a day
Vicodin extra 1, 4-5 times a day
Iron 325 mg 1 - 2 times a day
Case
The ED nurse hands you the following information:
BP 98/56, P 112, RR 16, T 37.6, Wt 82 Kg
Na 146, K 2.9, Cl 114, HCO3 32, BUN 26, Cr 1.4, glucose 54
WBC 6400, Hgb 14.8, Hct 46%, Platelet 273,000
Albumin 3.8, Alk Phos 68, TBil 1.2, AST 24, ALT 22
INR 0.98, PTT 32, CK 427, MB 6.3, MBI 1.5, troponin <0.03
Initial Differential Dx
What is the most likely cause of abdominal pain?
A) Cardiac
B) Gastric/Liver/Pancreas
C) Vascular
D) Neurological
E) Muscular
F) Infectious
G) Metabolic/Endocrine
H) Intestinal
I)
Neoplastic
J)
Other
Obtain and Review the H&P
Exam
Vitals: BP 98/56, P 112, RR 16, T 37.6, Wt 82 Kg
HEENT: dry oral mucosa
Abdomen: slightly distended, old midline scar from pelvic surgery,
old scars from prior G-tube and colostomy that was reversed,
tympanic to percussion, no HSM, no ascites or other stigmata
of chronic liver disease, diffusely tender, but more in LLQ, no
peritoneal signs, slightly hyperactive high pitched bowel
sounds
Pelvic: blind vaginal cuff without discharge or tenderness
Rectal: normal tone, non-tender, no blood
Extremities: tachycardic pulses, thready, poor skin turgor
Rest of exam is normal
Assessment
What is the most likely cause of abdominal pain?
A) Cardiac
B) Gastric/Liver/Pancreas
C) Vascular
D) Neurological
E) Muscular
F) Infectious
G) Metabolic/Endocrine
H) Intestinal
I)
Neoplastic
J)
Other
Plan
What initial test(s) will you order?
A) Additional cardiac enzymes
B) AAS
C) CT Abdomen/Pelvis
D) Pancreatic enzymes
E) Abdominal U/S
F) Blood and urine cultures
G) ABG
H) CT Chest Angiography
I)
Other
H&P
HPI: This is a normally independent 56 year old woman who lives
alone and presents with 7-9/10 severity, intermittent, achy,
pressure-like, sometimes sharp, left-sided abdominal pain,
lasting hours to days that began 2 months ago, initially with a
frequency 1-2 times per week, and now progressing to nearly
daily occurrence for the past week, associated with 1 week of
constipation and nausea but without emesis or distention. The
pain is exacerbated by eating solids more than liquids but
unaffected by positional changes of the body and does not
radiate anywhere, but is somewhat improved with eructation
and flatus, as well as Vicodin which reduces severity to 3/10.
She has reduced dietary intake for 2 days associated with
dizziness and weakness, as well as clouded thinking and
sweating. She denies alcohol use, hematemesis, BRBPR, or
diarrhea.
PMHx includes pancreatitis in 1994 and Ovarian cancer in 2005.
What is Assessment now?
What is the most likely cause of abdominal pain?
A) Cardiac
B) Gastric/Liver/Pancreas
C) Vascular
D) Neurological
E) Muscular
F) Infectious
G) Metabolic/Endocrine
H) Intestinal
I)
Neoplastic
J)
Other
Evaluate H&P
Summary: HPI
HPI: 7 elements of the chief complaint
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Location
Quality
Chronology/Duration
Severity/Intensity
Associated Symptoms
Aggravating or Alleviating factors
Impact or intervention
Symptoms associated with differential diagnoses for chief
complaint, whether positive or negative (ROS pertinent to
chief complaint)
Important past history or prior work-up that relates to chief
complaint
Avoid PMHx in first sentence unless VERY pertinent
Summary: Past History
Past Medical History:
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Explain all medications with associated Dx
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Approximate onset and current status of problem
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Describe specifics if known (complications, how Dx made)
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Describe laterality (right shoulder pain, etc) or location (left
arm DVT, etc)
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Determine nature of allergic reaction, if known
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Determine how medications are taken
Family History:
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Focus on genetically transmitted conditions, infectious
exposures, cause of death
Social History:
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Focus on living situation, relationship, employment,
independence, habits, environmental exposures
Summary: ROS and Exam
ROS:
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List by system and label the system
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Do not repeat or contradict what was in HPI (copy/paste or
templated ROS that is not carefully edited)
Exam:
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List by system and label the system
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Findings should reflect current exam (avoid copy/paste or
templated exam that does not apply to patient)
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Include pertinent negatives for what you were looking for as a
result of presenting problem (rather than templated “standard”
negative findings)
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List only what you actually examined and only examine what
was clinically indicated for patient’s current status (avoid
copy/paste or unedited templates)
Summary: Data
Data:
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List findings pertinent to indication for why test was ordered
(avoid copy/pasting entire reports or impressions)
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List “unexpected” findings only if they are clinically impactful
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Trend results if trending reveals important nuance that may
not be easily appreciated based on single value
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Indicate if you personally interpreted the data or coordinated
interpretation with another specialist
Summary: Assessment
Assessment:
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Commit to a Dx or symptom followed by differential Dx, even if not
certain (probable, possible, likely, or unlikely are ok)
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Avoid a summary of findings without associated Dx
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Avoid “rule out” terminology, “FEN,” or “prophylaxis”; indicate risk or Dx
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Indicate ICD-10 components:
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Dx or symptom followed by differential Dx and likelihood
Type or Stage
Acuity or severity
Location and/or laterality
Timing (present on admission, initial presentation, subsequent eval)
Etiology (pathogen)
Complication of Dx or associated co-morbidity
Summary: Plan
Plan:
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Each plan should have corresponding assessment(s)
Provide brief rationale for plan
Should logically follow from assessment
Include preventive measures on initial plan
Questions?
Demographics
Abdominal Pain:
Quali ty
Location
Dura tion
Severity
Associated Sx
Aggra vated by
Reli eved by
Impact
56 year old female
Achy, pressure -like, sometimes sharp [no burning, no ÒacidityÓ]
In the middle of abdomen, but off to the left usua lly
Lasts hours to days, [happening for past 2 months, sometimes 1-2
times/wk, now almost every day for past week]
10/10 since last night, but usua lly 7/10, [comes and goes,
sometimes no pain]
Nausea for past 2 days, no vomiting, [no Òacidity,Óno hematemesis,
no blood in stool, no fever or chill s, no diarrhea, no radiation to
back, no diverticulosis, no EtOH; positive constipation x 1 week]
Eating makes it worse than drinking since yesterday [unchanged by
position]
1-2 Vicodin reduces pain to 3/10, [a li ttle better with burping o r
flatus; unchanged by position]
[I can no longer eat, sometimes feel dizzy, sweaty, cloudy thinking]
HTN
Dx 1985 [took meds today, home BP 130s/80s but rarely measure,
Atenolol 100 mg qHS, Fosinopril 10 mg BID (20 mg/day), Lasix
20 mg/day for leg edema, no known Dx of CHF, no orthopnea]
Hyperlipidemia
Dx 1989 [Lipitor 40 mg QHS, no muscle aches, no h/o elevated
LFTs from Lipitor, liver failure in 1994 was from sepsis]
Diabetes II
Dx 1991 [took meds today; Glyburide 10 mg (two 5 mg tabs) in
AM and 5 mg in PM after meals; AM glucometer < 150, but rarely
checks; dimi nished diet and positive hypoglycemic Sx (dizzy,
sweaty, cloudy thinking) since yesterday; do not know HgbA1c
Pancreatitis
Dx 1994 [due to gallstones, had ERCP with sphincterotomy 1994
prior to cholecystectomy, no EtOH, led to DKA, no epigastric pain,
no vomiting, no radiation of pain to back; positive nausea]
Liver Failure
Dx 1994 [due to sepsis, no EtOH, no hepatitis, no stigmata of
chronic liver disease (ascites from ovarian cancer resolved after
chemotherapy)]
Sepsis
Dx 1994 [due to cholecystitis, was in ICU Òfor long time,Óhad
trach/PEG, subsequently removed, complicated by PE, pathogen
not known]
PE
Dx 1994 [Complication of sepsis, treated with Coumadin Òfor long
timeÓbut not more than 1 year, no SOB, no CP, not sure if IVC
fil ter placed]
Pulmonary edema
Dx 2005 [drained fluid from right lung caused by cancer, resolved
after chemotherapy, no known h/o CHF, no orthopnea; positive leg
edema for years; no known Echo]
Ovarian Cancer
Dx 2005 [had chemotherapy (does not know drugs) from 20052007, s/p TAH/BSO/debulking with colostomy and takedown 2006
ROS:
General
HEENT
Respiratory
Cardiovascular
GI
GU
Musculoskeletal
Neurological
Endocrine
[No fever, chill s, weight change]
[No vision, hearing change, no nasal congestion or sore throat;
positive for dry mouth x 1 day]
[No SOB, cough, sputum, orthopnea]
[No CP, palpitations, DOE, no prior stress test, can usua lly clim b
up 1 floor stairs]
As per HPI Ğ see abdominal pain
[No dysuria or polyuria, menopause at age 47]
[No joint pain or swelli ng; chronic leg edema since 2005, better
with Lasix]
[No focal numbness, weakness, seizure, neuropathy]
[No polydipsia, polyuria; positive hypoglycemix Sx for 1 day]
FHx:
Mother: DM, breast cancer, d. age 68
Father: CAD, d. MI age 49
Siblings: 2 have DM
Children: 3, healthy
SHx:
Immi grated to US from Greece at age 17, married at age 19,
divorced 1995, former art teacher, li ves alone in first floor
apartment o n disabili ty, independent, still paints, daughter li ves
nearby, never smoked, does not drink except special occasion, no
illi cit drugs
Allergies:
ÒI think PCN when I was a youngÓ(reaction not known)
Medications:
Atenolol 100 mg qHS
Fosinopril 20 mg/day [(total); 10 mg BID]
Lasix 20 mg/day
Glyburide 15 mg/day [(tot al) after meals; two 5 mg tabs in AM, one
5 mg tab in PM]
Lipitor 40 mg qHS
MVI 1 daily
Ca/Vit D, 1 tab BID
Vicodin ES, 4-5 times/day [uses 1-2 (10 mg) tabs q4-6h PRN]
FeSO4 325 mg 1-2 times/d, [325 mg BID, sometimes skips one
dose due to constipation]