The Written Medical
Record
Communication Skills II
Purpose
•
•
•
•
•
•
Memory Aid
Communication
Quality Assessment
Research
Legal Matters
Insurance Matters
Your Audience
•
•
•
•
•
•
•
•
You
Other Health Care Providers
Lawyers
Quality Assurance
Utilization Review Committees
Administrators
Insurance Companies
Researchers
Types of Notes
•
•
•
•
•
Complete History and Physical (H&P)
Problem Focused Note
Interim Note
Surgery/procedures
Hospitalization
– Admission Note
– Progress Note
– Discharge Summary
Organization of Notes
• SOAP format
– Subjective
– Objective
– Assessment
– Plan
Organization of Notes
• Subjective
–
–
–
–
–
–
–
–
Identifying Data
Source/Reliability
Chief Complaint
History of Present
Illness
Past Medical History
Family History
Patient Profile/Social
History
Review of Systems
• Objective
– Physical Exam
– Laboratory Data
• Assessment
– Problem List
– Impression/Diagnosis
• Plan
– Treatment
– Disposition
Subjective
• Identifying Data
–
–
–
–
–
Name
age
gender
occupation
marital status
• Source/Reliability
– historian’s identity
– reliability judgement
• Chief Complaint
– verbatim
– QUOTES
Subjective
• History of Present Illness
–
–
–
–
–
–
–
Selection and interpretation`
Detailed chronological description
Date symptoms and events
Absence of key symptoms
Relevant facts from PMH, FH, SH, ROS
Positive data before negative data
Symptom vs sign
Subjective
• Past Medical History–
–
–
–
–
–
–
list, dates, other relevant information
illnesses, hospitalizations and surgeries
accidents and injuries
pregnancies, deliveries, complications
allergies and reactions
medications including OTCs
immunizations and health maintenance
Subjective
• Family History
– history of family illnesses
• major
• genetic/hereditary/familial
• cause of death
– tabular or genographic
– three generations
Subjective
• Patient Profile and Social History
– Brief biographical narrative
•
•
•
•
•
•
birth, education, military
living situation
occupational history
life style - personal interests, travel
typical day
relevant feelings and beliefs
– List
• health habits - EtOH, tobacco, drugs
• diet, exercise
Subjective
• Review of Systems
– List all positive and negative findings in
complete sentences
– See pages 26 and 869
Subjective
• Identifying Data:
– Mrs. Reynolds is a 58-year-old bank executive
who lives with her husband and mother-in-law.
• Source:
– Mrs. Reynolds provides her own history and is
reliable and accurate.
• Chief Complaint:
– "I can't eat" for the past 3 or 4 months.
Subjective
• History of Present Illness
– The patient, who has a 10 year history of diabetes
and hypertension, complains of anorexia for the
past a 3 to 4 months and a 19 lb weight loss. She
tires easily and has been obliged to stop volunteer
hospital work and take a nap each afternoon. She
thinks this may well be related to her nerves since
she has been depressed about her divorced
daughter. She denies nausea, vomiting, diarrhea,
excess thirst, polyuria, headache, dizziness, visual
disturbance, dyspnea on exertion, swollen legs, and
palpitations
Subjective
• Past Medical History
– Allergies - sulfa (rash/hives)
– Childhood illnesses - chicken pox, scarlet fever
– Adult illnesses • diabetes mellitus, type II, X 10 years
• hypertension diagnosed 1991
– Hospitalization/Surgery
• Cholecystectomy 1981
Subjective
• Past Medical History (con’t)
– Obstetrical History - G3P3003
– Medications
• Glucophage 1000 mg BID
• Avandia 4 mg qd
• Prinivil 20 mg qd
– Immunizations/Health Maintenance
• Hepatitis B series - 2000
• Tetanus 1999
• Last pap - 9/2000; mammogram - 9/2000
Subjective
• Family History
–
–
–
–
–
–
–
Father - 32 years old; accidental death; diabetes
Mother - 80 years old; deceased - stomach cancer
Sister - 56 years old; alive and well
Sister - 55 years old; hypertentsion
Brother - 60 years old; diabetes
2 sons (20 and 22 years old) - alive and well
Daughter 26 years old - alive and well
Subjective
• Patient Profile
– Mrs. Smith is an intelligent, somewhat anxious woman who
shows normal concern for her symptoms and possible
illnesses. She thinks her troubles are due to nerves but
isn't sure. She is a sturdy, considerate, kind woman who
cares for her husband and seems well adjusted. She has
lived in Pennsylvania all her life until 7 years ago when
she moved to Virginia due to her husband's work. He is a
construction foreman and has always provided well.
Subjective
• Patient Profile (con’t)
– Mrs. Smith dropped out of college to get married and
although her formal education stopped she has kept busy
reading, doing charity work, and watching TV. She knits,
likes to dance, although she fatigues too much for that
now, attends church regularly, and seems to have good
psychosocial and sexual relationships with her husband.
She gets to bed by 11, is up at 7, makes breakfast and
lunch for her husband, naps in the afternoon, makes
dinner, and she and her husband clean up together.
Subjective
• Social History
–
–
–
–
–
Smoking - none
Alcohol - one or two cocktails on weekends.
Recreational drugs - denies
Caffeine - two to three cups of coffee or tea daily
Diet - Cereal and fruit for breakfast; sandwich or salad
for lunch; rice, vegetable and meat or fish for dinner.
Does not snack.
– Exercise - none
Subjective
• Review of Systems
– General: There have been no chills or fever and she
considers herself in good health until recently.
– Head: She has no headaches or dizziness.
– Skin, Hair, Nail: She has had thinning of the hair for 10
years. Here are no unusual nails or skin changes .
– Eyes, Ears, Nose, Throat: She wears glasses and has no
spots before the eyes, visual difficulty, inflammation or
eye pain, double vision, or tearing. She has good hearing
and no tinnitus or aural discharge. She has no teeth and
wears dentures. She gets a little hoarse sometimes but
attributes this to her husband's deafness.
Subjective
•
•
•
•
•
You will not record ALL of the data
Pertinent negatives
No assessment, diagnoses or impressions
Pain scale, activity
Symptom vs sign
Objective
• Physical exam findings
– general statement and vital signs
– fully describe:
• skin, HEENT, neck, lymph, breasts, lungs,
heart, abdomen, rectum, GU, (extremities),
musculoskeletal, neurological, mental status.
– Known laboratory/procedure results
Objective
• Location - landmarks,
clock
• Incremental grading murmur, strength
• Discharge
• Illustrations
• Organs, masses, lesions
–
–
–
–
–
–
–
–
texture/consistence
size
shape and configuration
mobility
inflammation
color
location
other
Assessment
• Problem list
–
–
–
–
–
known diagnoses
symptom
sign
laboratory abnormality
personal, social, financial, functional difficulty
• Diagnoses
– diagnosis with rational from database or
– prioritized differentials
Plan
•
•
•
•
•
Tests to be performed or ordered
Therapeutic treatment/medication
Patient education
Referral
Follow up
DO
•
•
•
•
•
•
•
Use outline format
Use headings
Be concise
Be accurate
Use quotes
Write legibly
Line out errors
•
•
•
•
•
•
•
Initial & date changes
Defer w/ reason
Use complete sentences
Use present tense
Use ink
Sign properly
Document soon
Do NOT
•
•
•
•
•
•
•
•
Identify patient
Use abbreviations
Use good, negative, normal, abnormal
Record false data
Obliterate errors or erase
Omit data
Leave blank spaces
Take copious notes/write too soon