DOCUMENTATION IN YOUR 3RD
YEAR AND BEYOND
Summer Quarter 2011
Amanda Kocoloski and Whitney Crye
OVERVIEW
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General principles of documentation
Types of Notes, the case of Sarah Bell
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Admit Note
Pre-Op Note
Procedure Note
Operative Report
Post-Op Note
Progress Note
Discharge Summary
L&D Admit Note
Labor Note
Medication Prescriptions
Assignment: Admission Orders
INTRODUCTION TO HOSPITAL CHARTING
Everything must be recorded somewhere!!!
 When starting a new rotation become familiar
with the chart ASAP
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Paper vs. EMR
Always: Date, time, and sign with rank
SAMPLE PATIENT: SARAH BELL
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Sarah 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 admits to some discomfort
and within the last day little abdominal pain that comes
and goes. Last bowel movement 2 days ago. No nausea or
vomiting.
O: VS: T: 99.1 BP: 120/65 P: 90 R: 14 pain: 4/10
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CV: S1 S2 no murmurs, no gallops
Lungs: clear bilaterally, no wheezes, rhonchi, rales
Abdomen: soft, irreducible mass in right groin below inguinal
ligament appreciated, no erythema, mild pain with palpation.
Flat, bowel sounds present, no rebound, no guarding,
GU: no labial masses
LE: warm no skin discoloration, +2/4 patellar and Achilles
DTRs bilaterally, pulses palpable,
A/P: 35 yo f with femoral hernia. Plan:1. admit to hospital
2. consult surgery
SARAH GOES TO THE HOSPITAL
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Sarah 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/HISTORY & PHYSICAL
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CC: Pt is a 35 yo f presenting with a “bulge” in her groin
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HxCC: duration 2 months. It used to go away when she laid down but recently it remains even when supine. She admits to some
discomfort and within the last day a little sharp abdominal pain that comes and goes. Dull pain in groin 4/10. Last bowel movement
2 days ago. Motrin seems to help with the pain, coughing makes it worse. No nausea or vomiting. Ibuprofen was given in the ER
which helped.
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PMH: HTN
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PSH: none
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Meds: HCTZ
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Allergies: NKDA
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SHx: non-smoker, no alcohol, no illicit drug use; LPN by profession, married, 2 children
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FHx: Mom alive, HTN; Dad deceased at 46 of MI with hx of HTN
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ROS:
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General:
Skin:
HEENT:
Chest:
Abdomen:
GU:
Extremities:
Neurologic:
Hematologic:
Psychiatric:
Endocrine:
PE:
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VS
General:
Skin
HEENT:
CV:
Lungs:
GI:
GU:
Extremity:
Neurologic:
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Labs/Imaging: pelvic CT showed a femoral hernia of the right groin. No labs ordered as this time.
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Assessment:
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1. Femoral hernia.
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2. HTN- controlled
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Plan
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Admission Orders
SARAH PREPS FOR THE OR
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Sarah 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. Antibiotics 3. skin prep
 Permission:
chart
Informed consent signed/on
SARAH IN THE OR
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Sarah 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.
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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
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SARAH RECOVERS
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Sarah is now post op and resting. You arrive at 5 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 Vicodin.
Passed gas, no bowel movement.
O: VS most recent; Exam: CV, Lungs, Abdomen, GU,
Extremity; 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 Vicodin for pain management. Advance
diet and ambulation as tolerated. Continue to monitor
I/O. Performed pedal pump and strain counter strain of
both lower extremities, pt tolerated well.
DISCHARGE NOTE
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Admission/Discharge Dates: 7/2/11-7/5/11
Admission/Discharge Dx: Femoral hernia
Service: Surgery, Dr. Lotheissen
Referring Physician: Dr. Rhemy PCP
Consult: any physicians, service, dates
Procedures: date of surgery/procedure and type
Hx, PE: pertinent admission H&P and lab tests
Course: summary of treatment and progress
Discharge Condition: good, stable, fair, etc.
Medications: discharge meds, dose, refills
Instructions: restrictions, diet, care, symptoms to be
aware of
Follow-up: appointment and emergency contact
number
PRACTICE!!!
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Progress Note
 Mr.
Robert Sacamano
So, who wants to send
Mr. Sacamano home?
 Anything he’ll need to
complete treatment?
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OB PROGRESS NOTES
L&D ADMIT NOTE
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S: This ___year old female,
wks, G P , EDD
based on (dates or US at ___wks)
presents to L&D for
(labor ctx, bleeding, induction, c-section, PROM).
Document if the patient feels FM, ROM, feels ctx, bloody show. Last US? _______any
complications during pregnancy. (High BP, HA, change of vision, N/V, change of mental
status)
 Blood type, Rubella, Group B strep
 GYN Hx: age of menarche x interval btw periods x how long periods last (13x28x4); hx of
STI, abnl pap
 OB Hx: G_T_P_A_L_
 List any complications with previous pregnancies/deliveries
 PMH:
 PSH:
 Meds:
 Allergies:
 FMH: (congenital anomalies, blood problems, birth defects in both mom and dad)
 SHx: is father involved, good support?
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O: PE: includes-VS. HEENT, Neuro, Heart, Lungs, Abdomen (BS, Gravid, Fundal height),
Ext
 SVE: cm / effacement / stage
 Toco:
 FHT’s:
Assessment: ___ yo, G_P__, IUP @ ___ weeks
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Plan: Continue monitoring during induction with Pit at ____mu.
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LABOR PROGRESS NOTE
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S: Pt resting comfortably and notes increased
frequency and strength of ctx.
O: BP
P
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Any new observations as to the patients states
FHT:
SVE___/___/____
Toco: q____min or irregular, doublets or triplets
Pit___mu
A/P: ___yo G__P__at ___wks
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Continue labor and increasing Pit per protocol,
anticipate SVD
DELIVERY NOTE: VAGINAL DELIVERY
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Type: SVD
Procedure: vacuum-assisted, forceps, episiotomy,
laceration repair
Attending/Assist:
Anesthesia: type and person
Findings: Time of delivery, viable infant m/f, in
___position. ____Nuchal Cord, infant weight,
APGAR__&__. ___degree laceration repaired with____.
__vessel cord and segment collected. Placenta delivered
(spontaneous, manual) intact.
EBL:
Complications: If present, list (thick meconium, nuchal
cord, shoulder dystocia)
Condition:
DELIVERY NOTE: C-SECTION
Pre-operative Diagnosis: 38 week pregnancy, G1P0
 Post-operative Diagnosis: 38 wk, G1P1
 Procedure: Primary C-section
 Surgeon & Assistant: Dr. Will; Assist Student Dr
 Anesthesia: (General, epidural, spinal, etc.)
 Estimated Blood Loss: 500mL
 Findings: Include position (especially if breech),
gender of infant, weight, APGAR scores, normal
uterus, tubes & ovaries or describe if other than
normal
 Complications: if any or “none”
 Condition: e.g. patient tolerated procedure well,
transferred to recovery room in stable condition
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POST-PARTUM NOTE
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PPD#__ or POD#__
Subjective:
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Objective:
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Condition of patient: Patient resting comfortably in bed
Pain: Pain well-controlled, PQRST
Lochia: minimal, moderate, or heavy (greater than or less than a period)
Breast or Bottle feeding
Tolerating diet & liquids well
Ambulating with or without assistance
SOB, CP, Flatus, BM, Urinating, LE pain or swelling
Ask about birth control options
VS
Rh & Rubella status
Heart:
Lungs:
Abdomen: Bowel sounds present, if c/s dressing dry or dressing removed and
incision healing well. Note any JP drainage. Fundal height, consistency, distension,
tender
Urine output: voiding without difficulty, is Foley in place, urine clear
Extremities: swelling, signs of DVT- size or color discrepancy, Homan’s sign
Labs: pre  post (note if pending)
Assessment/Plan:
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1. 24 yo f, G1P1, PPD #1 s/p SVD 1st degree laceration, progressing well, pain wellcontrolled with Tylenol— encourage ambulation, prescribe birth control, consult
lactation specialist to address patient’s concerns, stool softener
ADMISSION ORDERS: ADCA VAN DIMLS
Admit to service of…
 Diagnosis
 Condition
 Allergies
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Vital Signs
 Activity
 Nursing
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Diet
 IV orders
 Medications
 Labs
 Special
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ADMIT
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Attending Physicians
Name
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Unit/Floor:
Medical
 Surgery
 Medical ICU
 Surgical ICU
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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
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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
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General condition of
patient at time of
admission
Stable
 Guarded
 Critical
 Code Status
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Condition: Stable
Code Status: Full Code
ALLERGIES
Medication, food or
environmental allergies
 Be sure to state the
reaction if known
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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
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
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
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 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
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List labs to be done and
state when labs should
take place
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Do you want the labs done
now or in the morning?
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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
SPECIAL
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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
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Secondary Diagnoses: HTN, DM type 2
 Condition:
stable
 Allergies: Penicillin- anaphylaxis.
 Vitals: q shift (every 8 hours) If temp is
greater than 100.5° 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 ORDERS
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!!
 Pocket Medicine: The Massachusetts General
Hospital Handbook of Internal Medicine (Pocket
Notebook)’
 250 Mistakes 3rd year medical students make
 Clinician’s Pocket Reference (Scut Monkey)
 www.medfools.com
 Medfools also has some sample personal
statements
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