DOCUMENTATION IN YOUR 3RD
YEAR AND BEYOND
Summer Quarter 2010
Merrian Brooks and Amanda Kocoloski
OVERVIEW
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General principles of documentation
Types of Notes, the case of Ineda Surgery
Admission Orders
INTRODUCTION TO HOSPITAL CHARTING
EVERYTHING must be written somewhere!!!
 H&P, progress notes, labs, orders
 Paper vs. EMR
 Example charts
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SAMPLE PATIENT: INEDA SURGERY
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Ineda is a 35 y/o f presenting to your office
(outpatient) with a bulge in her groin.
What do you want to know?
 Which aspects of the exam will you perform?
 What is your assessment?
 What is your plan?
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OUTPATIENT NOTE
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S: Pt is a 35 yo f presenting with a “bulge” in her groin
x 2 months. It used to go away when she lays down
but recently it remains even when supine. She denies
discomfort. Last bowel movement yesterday. No
nausea or vomiting.
O: VS: T: 99.1 BP: 120/65 P: 90 R: 14 pain: 4/10
CV: S1 S2 no murmurs, no gallops
 Lungs: clear bilaterally, good excursion, good air movement
 Abdomen: flat, bowel sounds present, no rebound, no
guarding, soft, irreducible mass in right groin below
inguinal ligament appreciated, no erythema, no pain with
palpation
 GU: no labial masses
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
A/P: 35 yo f with femoral hernia. Plan:1. admit to
hospital 2. consult surgery
INEDA GOES TO THE HOSPITAL
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Ineda presents to the ER after her doctor calls
ahead. You are sent to admit her to the floor.
What do you need to know?
 What kind of exam will you do?
 What is your assessment?
 What is your plan?
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ADMISSION NOTE
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Full H&P related to CC
Add a sentence (or 3) about the ER course
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Assessment
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Pt has an irreducible mass beneath inguinal ligament that
is also evident on CT consistent with a femoral hernia.
Plan
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While in the ER pt received 200mg of ibuprofen, and a
pelvic CT scan that showed a femoral hernia of the right
groin.
Admission orders
Other elements may include: informant and
reliability, development/immunization (peds),
problem list (complex pt)
INEDA PREPS FOR THE OR

Ineda is admitted. She is scheduled to have
surgery the next day.
What lab values do you need?
 What else needs to be documented before surgery?
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SURGERY PRE-OP NOTE
 Pre-op
Dx: femoral hernia
 Procedure planned: Lotheissen-McVay femoral
hernia repair
 Labs: CBC, Chem 7, PT/PTT, UA
 CXR:
deferred
 EKG:
normal 3 months ago
 Blood:
type/screen, type/cross
 Orders:
1.NPO 2. skin prep
 Permission:
Informed consent signed/on chart,
INEDA IN THE OR
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Ineda goes into the OR and has a simple
herniotomy. Luckily the small bowel that is
trapped in the hernia is still healthy. Mesh is
placed at the hernia site.

What info should be documented?
PROCEDURE/OP NOTES
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Procedure / Indication: Lotheissen McVay for femoral hernia
Permission
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Physician / Assistants: Dr. Lotheissen DO, A. Kocoloski MSIV
Estimated Blood Loss (EBL): 2mL
Description
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I explained the risk/benefits and alternatives to the patient. The
patient voiced understanding. Consent form signed placed on chart.
Area prepped and draped in sterile fashion, Epidural anesthesia
administered with Bupivicaine 0.5%. The abdominal wall was cut
and the transversalis facia divided. The hernial sac was identified
and small bowel was present in the canal. The bowel was healthy and
removed from the hernial sac. Coopers ligament identified. Ethicon
prolene mesh was placed over region. Sutures placed.
Complications: none
Disposition
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Pt a/o, resting, breathing quietly, extremities neurovascularly intact.
Incision clean, dry, intact. In stable condition.
SURGERY POST-OP NOTE
Pre-op diagnosis: femoral hernia
 Post-op diagnosis: femoral hernia
 Procedure: Lotheissen McVay femoral hernia
repair
 Surgeons: Dr. Lotheissen, A. Kocoloski MSIV
 Findings: femoral hernia at right groin region
with healthy bowel in the hernial canal
 Fluids: 1000mL lactated ringers
 Anesthesia: epidural
 Estimated Blood Loss: 2 mL
 Drains:none
 Specimens: none
 Complications: none
 Condition/ Disposition: stable

INEDA RECOVERS

Ineda is now post op and resting. You arrive at 4
am to do your pre-rounds.
What do you want to know?
 What exam do you want to do?
 How will your assessment be different?
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HOSPITAL PROGRESS NOTE
 Brief
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note concerning past 24 hours
S: Pt did well overnight. Pain controlled with ibuprofen.
Passed gas, no bowel movement.
O: VS most recent; Exam: CV, Lungs, Abdomen, GU;
Incision: clean, dry and intact. Osteopathic: bogginess
at right thigh, increased tissue tension of right gluteal
muscles. Recent labs.
A/P: Pt is a 35 yo f pod#1 s/p right femoral hernia
repair and right lower extremity somatic dysfunction.
Will continue ibuprofen for pain management. Advance
diet as tolerated. Continue to monitor I/O. Performed
pedal pump and strain counter strain of both lower
extremities, pt tolerated well.
PRACTICE!!!
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
Group 1. Hospital
Progress Note A
Group 2. Procedure
Note:
http://www.youtube.co
m/watch?v=R2_0gOI8
uV0&feature=related

Group 3. Hospital
Progress Note B
ADMISSION ORDERS: ADCA VAN DIMLS
Admit to service of…
 Diagnosis
 Condition
 Allergies

Vital Signs
 Activity
 Nursing

Diet
 IV orders
 Medications
 Labs
 Special
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ADMIT

Attending Physicians
Name
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Unit/Floor:
Medical
 Surgery
 Medical ICU
 Surgical ICU


If the family physician is not
the same as the attending, you
can notify the family doctor as a
courtesy.
Admit: Dr. Duerfedlt,
Medical Floor
Notify: Dr. D.O. of
patients admission
DIAGNOSIS

List both the diagnosis
that caused the patient
to be admitted (primary)
and any other
diagnosis(es) that the
patient currently carries
Diagnosis: Pneumonia
Secondary Diagnoses:
Hypertension, DM Type
2
CONDITION

General condition of
patient at time of
admission
Stable
 Guarded
 Critical
 Code Status

Condition: Stable
Code Status: Full Code
ALLERGIES
Medication, food or
environmental allergies
 Be sure to state the
reaction if known

Allergies: Penicillin;
anaphylaxis
VITALS
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Frequency: How often do
you want this patient’s
vitals checked
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Is the patient’s condition
one which you may expect
a change over a short
period of time?
Parameters
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When should the doctor be
called
Vitals: q shift (every 8
hours)
Notify H/O if BP<90/60,
>160/110; Pulse >110 or
<60; temp>101.5;
UOP<35cc/h for>2hours;
RR>30
*H/O = house officer
ACTIVITY
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Restrictions on patients
activity
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Bed rest
Bedside commode
Up Ad Lib
Bathroom privileges
Ambulation
Up in chair
Up with nurse assistance
Fall precautions
Seizure precautions
Isolation
Activity: Bathroom
privileges, Fall Precautions
NURSING
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Any special functions
that the nurse must
carry out and frequency
if applicable
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I/O’s
Oxygen (some docs put
this other places too)
Pulse oximeter
Accu checks
Drain and/or catheter
instructions
Incentive spirometry
Wound care
Stool guaiac
Nursing:
O2 2L via NC titrated to
maintain sats at or
above 95%
Continuous pulse oximetry
Accuchecks AC and HS
Incentive spirometry q 2
hrs while awake
DIET
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State any dietary
restrictions
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NPO (nothing per oral)
Ice chips only
Clear fluid only
Soft
Full
Thickened liquids
2200 calorie ADA
Cardiac
Low sodium
Low residue
Regular diet
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Diet: 1800 ADA diet
IV
*THIS SECTION IS RESERVED FOR IV FLUID ADMINISTRATION, NOT FOR IV
MEDICATIONS*
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If ordering IV fluids,
state
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Type of fluid (Normal
Saline, Lactated ringer etc)
Additives (KCL, MG)
Rate in ml/hr at which fluid
should be run
Endpoint for infusion
Maintenance fluids
Rehydration
Heplock
KVO
None
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IV: 0.9 NS KVO
MEDICATION
List medication specific to patients primary diagnosis
 List other meds that patient is currently taking that you
want continued throughout admission
 List PRN medications (i.e. pain, fever)
 Include dose, mode of administration

 Can
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vary the dosage or the dosing interval, not both
Be sure to include insulin orders here for patients
getting Accuchecks
EXAMPLE: MEDICATION
Levaquin IV 650mg q day
 Tylenol 500 mg PO q 4-6 hr prn HA or fever greater
than 101
 Ambien 10 mg PO @ hs prn insomnia
 Sliding scale coverage of accuchecks using low-dose
algorithm
 Duo-neb treatments q2hr prn SOB or wheeze
 Duo-neb tx q 6hours
 Mucinex 600mg PO Q 6hrs
 Lisinopril 10 mg PO Q day
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LABS

List labs to be done and
state when labs should
take place

Do you want the labs done
now or in the morning?

Remember admission orders
are in place until the
attending physician takes
over patient care and
changes orders. Think of
what labs the attending will
want to see when he or she
evaluates the patient.
Blood culture: now
 Sputum culture: now
 CBC, chem 7: in am
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SPECIAL

Are there any special
orders
Ancillary services
 Radiology
 Consults
 Special preps

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Respiratory therapy to
follow
ADMISSION ORDERS
 Admit
to: Dr. D on med-surg floor
 Dx: pneumonia

Secondary Diagnoses: HTN, DM type 2
 Condition:
stable
 Allergies: Penicillin- anaphylaxis.
 Vitals: q shift (every 8 hours) If temp is
greater than 102° call attending
 Activity: Bathroom privileges, fall precautions
 Nursing: O2 2L via NC titrated to maintain
sats at or above 95%. Continuous pulse
oximetry. Accuchecks AC and HS. Incentive
spirometry q 2hrs while awake.
ADMISSION ORDER
Diet: 1800 ADA
 IV: 0.9 normal saline to
KVO
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Labs
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Blood culture: now
Sputum culture: now
CBC, chem 7: in am
Special: Respiratory
therapy to follow
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Medications
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Levaquin IV 650mg qd
Tylenol 500mg PO q 4-6 hr
prn HA or fever greater than
101
Ambien 10 mg PO @ hs prn
insomnia
Sliding scale coverage of
accuchecks using low-dose
algorithm
Duo-neb treatments q2hr prn
SOB or wheeze
Duo-neb tx q 6hours
Mucinex 600mg PO Q 6hrs
Lisinopril 10 mg PO Q day
NOTE-WRITING RESOURCES

Maxwell Quick Medical Reference
A must-have!! Only $7.95!!
 DO or MDPocket is an alternative but is $25.00

How to be a truly EXCELLENT Junior Medical
Student
 250 Mistakes 3rd year medical students make
 Clinician’s Pocket Reference (Scut Monkey)
 www.medfools.com


Medfools also has some sample personal statements