outline the patient chart admission note (history and physical) progress notes discharge notes ...
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Outline
The Patient Chart
Admission Note (History and Physical)
Progress Notes
Discharge Notes
Operative Notes
Pre and post-operative
Procedure notes
www.pptbackgrounds.net
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The Patient Chart
Chart is located at the patient bedside,
electronically or at nursing station
Essential components of the chart
Admission notes, physicians Orders, administered
medications, vitals, progress notes, laboratory and
radiographic examinations and discharge summary
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The Patient Chart
Important medical and legal document
Need to write legibly and sign your notes !!
Everything you write must be co-signed by and
attending physician or by your senior resident !
Always date, time and sign your notes !
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The History and Physical (H+P)
Initial note for a patient admitted to the hospital
Summarizes:
Why the patient came to the hospital
Medical history prior to this admission
Initial physical exam to include initial labs/studies
Gives the physician the opportunity to formulate a
differential diagnosis and treatment plan
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The History + Physical (H+P)Tips
Always welcome the patient – ensure comfort
and privacy
Know the patient’s name
Introduce and identify yourself
Set the agenda for the questioning
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H+P Components
Chief complaint
History of Present
Illness
Past Medical History
Past Surgical History
Allergies
Medications
Social History
Family History
Review of Systems
Physical Exam
Labs/Studies
Assessment and Plan
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Chief Complaint (CC)
This is why the patient is in the Emergency
Room or in the office seeing you “This is in the patients own words”
Examples: Shortness of breath
Chest pain
Nausea and Vomiting
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History of Present Illness (HPI)
Detailed reason why patient is here
Use the OPQRSTA approach to cover information
Begin by listing all the relevant major medical
problems in first sentence
Mr. Morris with history of hypertension, diabetes,
obstructive sleep apnea and osteoarthritis presented to
the hospital with ……
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OPQRSTA Approach Onset:
When did the CC occur Prior occurrences Progression
Is it getting worse or better?
What makes it better or worse
Quality Is there pain, and if so
how would you describe it?
Radiation of Symptoms
Scale On scale of 1-10, how
bad are the symptoms Timing
When do they occur? Associated symptoms
Any other symptoms not already covered
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HPI Continued
Include in this section a brief synopsis of what
was done in the ER or at an outside hospital
Example: 50 year old male with hypertension, diabetes, obstructive sleep apnea and osteoarthritis presented to the hospital complaining of fevers, chills and a cough for the past week. The cough started approximately one week ago, was productive in nature, and had an occasional blood tinge to it. The patient says that the fever and chills began two days ago and has prevented him from sleeping at night. Incidentally, the patient’s brother, who was visiting from Herat, was recently ill with similar symptoms.
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Past Medical and Surgical History
Major disease(adult and childhood) with brief discussion of
duration and treatment
Ex: Hypertension x 10 years well controlled on medications,
s/p stroke in 1991 with residual left sided weakness
Hospitalizations (Reason for admissions, when and where?)
Surgical procedures with dates (Indications)
Example: Open Cholecystectomy at age 46
Immunizations
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Other Components Medications:
Dosage and duration
Does patient take the
medications?
Over the counter and herbal
medications
Allergies:
Record allergies and reactions
to medications, foods and
latex
No known drug allergies
Social history:
Occupation
Tobacco, alcohol or illicit
drug use
Marital and children status
Family History:
Include inherited diseases
Ex: + Diabetes in mother and
sister
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Review of Systems (ROS)
Series of questions based on organ system: General/Constitutional
Skin/Breast
Eyes/Ears/Nose/Mouth/Throat
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Neurologic/Psychiatric
It is acceptable to write: ROS as per HPI, otherwise
negative
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Physical Examination
General (Always include vital signs)
HEENT (Head, eyes, ears, nose, throat)
Heart
Lungs
Abdomen
Extremities
Skin
Neurology
You must do a Physical Examination !!!
Need to develop a systematic approach for doing the physical examination !
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Labs and Radiographic Studies
Admission labs and important studies
Example:
Complete blood count
Chemistry panel
Cardiac enzymes
EKG
Chest X-ray
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Assessment and Plan
Assessment of the patient:
This is what you think is wrong with the patient
Start with a short summary of 3-4 sentences
maximum
Follow by listing each active problem numerically
with most important first
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Assessment and Plan
Assessment of the patient: Each problem you list requires an in depth assessment
which includes a differential diagnosis
Support your thoughts with elements of the patient’s
history, physical, lab results
Plan:Conclude with a detailed treatment plan
Sign your note with resident year and phone number
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Example
Plan: The differential diagnosis includes bacterial pneumonia, tuberculosis, viral pneumonia, or less likely pulmonary sarcoid.
1. Pulmonary Infection:- Obtain blood cultures x 3- Obtain sputum cultures and smear x 3- Start appropriate antibiotics for community acquired pneumonia- Initiate primary tuberculosis treatment- Admit to hospital with appropriate isolation precautions: respiratory and droplet precautions
2. Hypertension:- Continue outpatient medications 3. Diabetes:- Continue outpatient diabetic medications- Institute an insulin sliding scale
Assessment: The patient is a 50 year old male with hypertension, diabetes, and obstructive sleep apnea who presents to the hospital with a respiratory infection.
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www.maxwellbook.com
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Progress (SOAP) Notes
Every inpatient should have a daily progress note
in the chart
This note allows you to:
Communicate your thoughts about a patient’s condition
Your treatment plan
And any progress that has been made over the past 24
hours
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S= Subjective
Summarizes how the patient feels
Includes pertinent events that occurred
overnight
Look through nursing notes or ask the nurse
about how the patient did overnight
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O=Objective
Objective information including:Vital signs
○ Temperature, blood pressure, heart rate, respiratory rate,
oxygen saturation and pain scale
○ I/O (“Ins and Outs”)
Pertinent physical exam findings
More recent labs and diagnostic test results
Current inpatient medications (include # of days on the
medication. For example, Gentamicin (7/14)
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A= Assessment
1-2 sentence summary of the prior two
sections which includes:Patient’s age, hospital day (if surgical patient include
post-op day), and disease process
For example:
○ 50 year old male admitted with heart failure ….
○ 50 year old male post-op day # 3 status post
appendectomy ….
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P= Plan
This section includes:
What you plan to accomplish over the next 24 hours
including medications, procedures, consults, or
discharges
Again, always sign your notes and provide a contact
phone number
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www.nexthospital.com
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Discharge Summary
Provides the patient and their outpatient
physicians with:
Brief summary of the patient’s presentation to
the hospital
The hospital course
And any further treatment recommendations
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Discharge Summary
Important Components of a Discharge Summary
(see attached example):
List the number one problem for the patient’s admission
List important admission labs, vitals, signs + symptoms of
the patient
Diagnostic work done during the patient’s admission
○ You can write in the discharge summary if there is any
work-up that is still pending at discharge
Need to write down who the patient is to follow-up with …
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www.heart-valve-surgery.com
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Pre-Operative Note
These notes are written on all surgical patients
This is essentially a checklist to confirm all the
required pre-op information has been collected
and patient is ready for surgery
This should be completed in the progress note
section prior to surgery
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Pre-Operative Note Format
Date and time
Pre-op diagnosis: Appendicitis
Procedure: Open
Appendectomy
Pre-op Orders: Nothing Per Oral
(NPO)
Labs: CBC, PT/PTT (record
results prior to the procedure)
CXR: No active disease (note the
findings)
EKG: Normal sinus rhythm (note any
abnormalities)
Blood: Typed and crossed for 2
units of O+
Consent: Singed on chart
Anesthesia: To see patient, or
patient seen, note on chart
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Operative Note
Pre-op Diagnosis: Appendicitis
Post-Op Diagnosis: Appendicitis
Procedure: Appendectomy (what was done?)
Surgeons: Attending, resident and students
who scrubbed in on the procedure
Findings: acutely inflamed appendix
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Operative Note
Anesthesia: general with endotracheal tube,
spinal, local, etc
Fluids: amount and type (electrolytes, blood); also
record the urine output
Estimated blood loss (EBL): amount in cc
Drains: List all in the patient after the procedure
Number, type and location
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Operative Note
Hardware: Relevant usually for orthopedics
Specimens: Type of specimen sent to pathology
Complications: List any complications
Needle and sponge count: correct x 2
Disposition: Stable, extubated, transferred to
recovery room
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Post-Operative Notes
Post-op checks are progress notes are usually
written 4-8 hrs after completion of case
Documents the patient’s immediate post-op
condition and progress
Use a modified SOAP note
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Post-Operative Notes
Status post (s/p): Procedure and indication
S: Subjective
Patient complaints or comments
CHECK consciousness (alert, oriented, drowsy),
ambulating
Taking oral medications
Pain control
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Post-Operative Note
O= Objective
Vitals: BP, HR, Respirations, Temp, O2 sat
INS/OUTS: IV fluid, PO intake, drains/tubes
Exam: Physical findings
○ Incisions/dressings -- clean, dry and intact (CDI)
○ Neurovascular status
Meds: Routine or new medications (Antibiotics, DVT
prophylaxis)
Labs: Results of labs since surgery
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Post-Operative Note
A/P: Assessment and Plan
Patient is stable/unstable/critical status post
procedure
Include problems and how you plan to address them
Plans for diet, ambulation, dressing changes, fluid
management, foley, drains, pain management and
etc.
Don’t forget to sign your name, date and provide a
phone number
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Procedure Note
After performing a procedure:
It is imperative that you document procedures
performed on patients in the patient’s chart
This allows other physicians to know what
occurred and can act if a complication should
arise later in the day
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Procedure Note Format
Procedure: What procedure did you do?
Permit:
Document that you explained and patient
understands the procedure
Discussed alternatives, risks, and benefits of the
procedure to the patient
○ Risks: Bleeding, infection, reaction to anesthesia,
general injury, etc)
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Procedure Note Format
Indications: Why did you do the procedure?
Physician (s): Who performed the
procedure?
Description: How did you do the procedure?
Where did you do the procedure?
What anesthetic did you use?
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Procedure Note Format
Complications: Did anything go wrong with the
procedure, bleeding, pneumothorax, infection?
EBL: estimate the amount of blood loss in cc’s
Disposition: How did the patient tolerate the
procedure?
Where will the patient go after the procedure?
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Any Questions ??
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References
Maxwell Quick Reference Book. 2006.