Transcript History and Physical

Hospital Documentation
H&P
Admit Note
Admit Orders
HISTORY AND PHYSICAL
…is the FULL work up
• SOAP format
• Subjective – What is the patient telling you?
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Chief Complaint
History of Chief Complaint
Review of Systems
Past medical history
Past surgical history
Family history/social history
Allergies/meds
SOAP format
• Objective – what do YOU find?
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Physical
Lab
X-ray
Other studies
• Assessment
• Plan
H&P
• Chief Complaint
• CC
• If using patients’ words, use “quotations”
• Ok to summarize
• History of Chief Complaint
• HCC or HxCC or HxPI
• “quotations” if using patients’ words
• Note if history is coming from someone other than the
patient themself
H & P cont.
• Past medical/surgical history
• Review of Systems
• ROS
• Pertinent positives AND negatives
• Get into a “flow”
• Is ok to have cheat sheets
ROS
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Integument/Skin
HEENT
CV
Pulmonary
GI
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GU
Neurologic
Musc/Skeletal
GYN
Endocrine
H&P cont
• Family History/Social History/Job/Religion
• Include habits here – smoking, alcohol, drugs
• Medications
• Don’t forget over the counter, vitamins and herbal
supplements
• Need to ask – most patients don’t consider these “meds”
• Allergies
• And what is the actual allergy (so you can distinguish
from a side effect)
H&P
• Physical Exam
• Again, use a logical flow
• ALWAYS start with vital signs
• BP, pulse, resp, temp, height, weight
• OK to use cheat sheet here as well
• Chart pertinent positives and negatives
• Don’t make up acronyms
• RRR is standard c/r/g/m/ is NOT
H&P
• Other –
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Lab
X-ray
Other studies
Old record review
H&P
• Assessment
• What does your physical and the lab, etc., lead
you to find?
• Ok to use symptoms if don’t have full diagnosis
• DON’T use the OSCE format
• No need to put 4 diagnoses here
• If they have a history of something can put it
here, but should NOT be the first listed
• (and you want to make sure state Hx of..)
Assessment, e.g.
• Pneumonia
• Hypokalemia
• Hx HTN (or can say HTN – controlled)
Plan – What are you going to do
with the patient?
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Admit
Start IV antibiotics
Replace electrolytes (correct electrolytes, etc)
Consult Pulmonary – anticipate bronchoscopy
(ok to write see orders)
Ok to write discussed the case with Dr. X
(seen with Dr. x present, etc)
ADMISSION (ADMIT) NOTE
Admit Note
• What you put as your first progress note
• Abbreviated version of H & P
• Can be the full H & P
• Entitle “Admit/H &P”
• No need to duplicate
…MUST contain
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CC
Hx cc
Pertinent physical (pertinent positives)
Assessment
Plan
ADMISSION ORDERS
…Instructions to the Nursing Staff
• What do you want done for this patient now
that they are coming into the hospital?
• Systematic approach
Admission Orders
• Admit to service of (insert doctor)
• Any special floor? (ICU, stepdown, telemetry)
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Condition
Allergies
Vitals
Activity
Diet
Admission Orders
• Medications IV
• Medications PO
• These include any over the counter as well
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Labs
X-ray
Other studies
Other
…so for our pneumonia
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ATSO Dr. Gail Feinberg
Condition – stable
NKDA
Vitals (q 4 hours, q shift)
Activity –
• ABR with BRP (Absolute Bed Rest with Bathroom
Privileges)
• Ambulation with assistance, no limitations, etc
Pneumonia cont
• Diet – regular as tolerated (1800 cal ADA,
salt restricted, cardiac – check with hospital
to see how these are categorized)
• Medications
• IV – 1000cc D5W.5NS с 40meq KCL/liter @
75cc/hr
• Rocephin 1gm IV daily (DO NOT USE qd)
• Xopenex nebs q8 hrs
Pneumonia cont
• Labs
• Blood Culture prior to first dose IV antibiotic,
sputum culture, CBC, CMP
• CXR – PA and Lateral
• Other
• Oxygen per protocol (2liters NC, only at hs…)
• Chest percussion after neb treatments
• Incentive spirometry q shift
Questions?