D A I LY I N P A T I E N T C A R E / D O C U M E N T A T I O N / P I N E C R E S TC H R I S T I A N S O N N I E R P G Y- 3

INTRODUCTION TO HOSPITAL MEDICINE

LEARNING OBJECTIVES

• Discuss daily inpatient care (do’s and don’ts)• Discuss daily inpatient documentation• What is Pinecrest, and how are these patient’s

unique?• Discuss general inpatient resident issues

DAILY INPATIENT CARE

• Morning check out: 6am • Between 6am-8:30/9:00am: see patients and

begin-finish notes. • 9:00-? Table rounds and walking rounds• After rounds-5pm: • Finish following up patients• Finish notes• Admits and clinic• Upper level caries pager until rounds are over then intern

takes pager after rounds (unless in clinic then give it to another resident)

DAILY INPATIENT CARE

• Always address any abnormal labs or events overnight• Watch I/O’s …you will flood patients but usually it is avoidable.• Do at least heart, lungs, abdomen on physical exam…apart from

that it should be focused• Constantly be trying to decrease/simplify care and move patient

toward discharge• Play as a team• Use other resident’s patients as a learning opportunity• Always reconcile home meds on admit• Always be on the look out for sirs/sepsis• Always ask about DNR/DNI-code status. Better to know in advance

vs an emergency• Listen to and respect upper levels and attending's• Remember orders/directives flow down hill • Maddenfacultyupper levelsinterns

DAILY INPATIENT CARE

• Do not• Show up late…be on time!• Forget to add patient to the list• Forget to finish notes or follow up on to do list• Leave the hospital unless your upper level gives ok and if you

do come back quickly• Do not leave things unfinished during the day for the night

float to follow up on (NF job is to put out fires and tend to emergencies and admits)

• Do not consult a specialist without calling them…• Do not guess on treatments…if you don’t know look it up or

ask!!!• Do not fake that you saw a patient if you did not…this is fraud

DOCUMENTATIONH&P’S

• H&P’s: regardless of obs, floor, ICU the following is true• Detailed HPI is needed: use OLD-CARTS or whatever else

you like as long as the information is there• Full ROS on every patient• Full physical exam on every patient• A/P show your work!• There should be a complete explanation as to why you think

the patient has what you think they do and what you plan to do about it

• The goal here is to provide complete and accurate info so that if another provider reads it they know exactly without a doubt what is going on and what the plan is.

EXAMPLES

• Good HPI• Pt is a 57 yo male with pmhx of htn, hld, cad, ckd, copd.

Presents to the ER today from home via personal vehicle for cp/sob. The patient reports onset of sx 4 hrs ago and describes pain as crushing and substernal with associated sob, nausea and diaphoresis. The pain has been persistant since onset and is made worse by activity and better with rest. Pain radiates to the neck and left arm with no associated weakness. He rates the pain currently as a 4/10 with the worst as a 8/10.

EXAMPLES

• Bad hpi• Pt is a 57 year old male presents to the ED with cp/sob.

Denies n/v/d. Pain started earlier today and has remained the same since onset.

WHAT MAKES A GOOD HPI

• The more information the better, remember to use OLD-CARTS• Onset• Location• Duration• Character• Aggravating/alleviating• Radiation• Timing• Severity

• Hpi is like a thesis statement in an essay…start out broad and narrow down to the present. It sets the stage for the rest of the note.

EXAMPLE: A/P

• Good a/p• Pt is a 57 yo male with history consistent with anginal

chest pain. At this point it is unclear if this cp/sob respresents active myocardial infection or unstable angina. We will admit the patient to r/o acs as well as other causes of cp/sob• 1) r/o acs

• Obtain ekg and ce q6 hrs x3• Start morphine, nitroglycerine, oxygen, asa• Will consider cardiology consult should ekg changes be present

• 2 copd exacerbation• Begin duoneb q4q2 prn• Obtain cxr, cbc, cmp and begin emperic abx with systemic

steroids if indicated

EXAMPLE A/P

• Bad a/p• 57 yo male with cp/sob• Plan:• 1) acs

• Ekg, ce, mona protocol• If negative look for other causes

DAILY PROGRESS NOTES

• Every Floor patient should have:• Subjective: a short narrative on how they did overnight.

Focused ros and new issues• Objective: vital signs and focused physical exam• Everyone needs at least: general, lung, cardio, abd

• A/P: • Same as H&P: discuss medical issues being treated and what

the rational and plan is• Do not copy/paste from the day before…this is fraud.

EXAMPLES

• Good Subjective• Patient doing well overnight. Denies cp/sob, n/v/d, f/c or

loc. No acute events overnight per nurse and patient.

• Bad subjective• Nad, no acute events overnight

EXAMPLES

• Good a/p• Pt is a 57 yo male with acs. So far CE show elevated

troponin on 2 of the 3 sets with no st elevations on ekg. Patient is stable on the MONA protocol and cardiology has been consulted. The patient has a LLL pneumonia on cxr and tx for copd exacerbation has been started.• Plan

• 1) acs vs nstemi• Positive troponins with no acute ekg changes• Cardiology to perform LHC in the am

• 2) copd exacerbaton• Likely 2/2 community acquired pneumonia. Will begin levaquin

750mg iv qday• Will continue duoneb q4q2prn and solumedrol 125mg IV q8hrs

EXAMPLES

• Bad a/p• Pt is a 57 yo with nstemi and copd• Plan

• Nstemi• MONA and LHC

• Copd• Solumedrol, levaquin and duonebs

DAILY ICU NOTES(NOT FOR YOU NOW BUT SOON)

• S: subjective: need to discuss any event that happened overnight, include any updates/concerns from nurse

• O: objective:• Include vitals, all labs• Full physical exam daily…no exceptions

• A/P• Every medical problem no matter how insignificant it may seem

needs to be addressed daily.• FAST HUGGS: needs to be documented daily…I don’t care how

or where but needs to be there.• Detailed and accurate A/P, again just like in H&P the goal is if

another provider reads the plan they should not have to ask you any questions

DISCHARGE NOTES

• Must be done within 24 hrs of discharge. No exceptions

• The goal is to provide an accurate, concise yet detailed account of why they were admitted, what did we do for them, and what is the plan after discharge

• Include HPI, hospital course, Discharge plan• Again the goal: if/when they are re-admitted

anyone should be able to read the summary and know exactly why they came in, what happened and what the plan was for leaving with out every having to ask you anything.

EXAMPLE

• Good hospital course• Pt is a 57 yo male who was admitted to RRMC for acs and

copd exacerbation. The patient was found to have an nstemi with elevated troponins as well as copd exacerbation 2/2 LLL pneumonia. Cardiology was consulted and treatment of NSTEMI consisted of MONA protocol as well as LHC with 2 stents (LAD and circumflex as each had 75% and 95% stenosis respectivly). The patient tolerated the procedure well and was started on daily asa 81 mg, will follow up with cardiology 2 weeks after discharge. COPD exacerbation corrected readily with solumedrol, duonebs and levaquin, patient did not progress to sepsis and will be dicharged with 5 days of levaquin 750mg po. Discharge patient today #/#/## and have patient follow up with pcp in 1-2 weeks.

EXAMPLE

• Bad hospital course• Patient is a 57 yo male with nstemi and copd

exacerbation. Had LHC and 2 stents per cardiology. Patient was stable on steroids, abx and neb tx. Will send home with rest of abx course, steroid taper and continued nebs. Will follow up in 1-2 weeks

WHAT IS PINECREST?

• Pinecrest is short for: Pinecrest Developmental Care Center.• Pinecrest is a throw back to an era when children

with developmental abnormalities like Downs, MR, cerebral palsy ect were left in homes to be wards of the state and taken care of. At the time (early 1900’s) this was the “standard of care”• Many of these institutions were closed however

Pinecrest remained open

WHAT IS PINECREST?

• Fast forward to today:• Pinecrest houses the following kinds of patients• Profoundly MR adults• Downs• Cerebral Palsy• Traumatic brain injury• Severe psychological diseases with no where else to go

Most of these patients are adults usually in their late 40’s-90’s. However this aging population is rapidly declining from death, NH placement ect so Pinecrest is beginning to accept pediatric patients with ODD, autism ect. So while you will usually see these patient’s on alpha, bravo may begin to see more of them too.

PINECREST PATIENTS

• Tips and unique situations• LSU is the only medicine service that admits Pinecrest

patients• Most patient’s are non-verbal so history will come from

sitters and Pinecrest notes which are notoriously unreliable• Patients frequently have traches and pegs however some

will not• Every Pinecrest patient on the floor has a sitter… do not

“feed” the sitters information as they only get paid when they are sitting in the hospital…some will frequently try to have the patient stay longer.

• Pinecrest patients have a tendency to be come sick quickly • Use caution when intubating, placing lines ect as the

patient’s commonly have anatomic abnormalities

PINECREST PATIENTS

• Common reasons for admits and things to consider• Aspiration usually with pneumonia• Pt are long term hospitalized therefore pneumonia=HCAP

every time. Vanc, levaquin and zosyn

• Uti• Gi bleed• Seizures• Misc• Peg tube issues• Ams• Always look for sepsis. If there is an infection on a Pinecrest

patient there is usually sepsis.

PINECREST TIPS

• Patients can not die at Pinecrest… • If we do happen to get a DNR from a family member get

a LaPost signed. It will be ignored at Pinecrest but if/when they return it is still usable.

• Try to discharge patients early in the day…as the day goes on the less likely Pinecrest is to take them back.

MISC:

• Always pay attention to the schedule• If there is any doubt call and ask • Do not assume you are off, if the schedule has you at

work or on call show up

• We will be spot checking notes if there are problems we will discuss them with you.

QUESTIONS?