Transcript Slide 1

A Briefing on Electronic
Progress Notes
Lynn Jacobs
Svetlana Yedreshteyn
Organizational Development & Learning
July 15th, 2009
Electronic Progress Notes
• Current method is going away
• Progress notes, to date, have been inadequate
and, at times, dangerous
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Inconsistent Documentation
A patient acutely deteriorates and codes. He is
admitted to the MICU and his wife is called.
Upon hearing he is in the ICU on a ventilator
the wife asks why we didn’t follow his living
will. The patient’s end of life wishes were
documented on a prior admission but not in
the current chart. Additionally, while the
attending knew the patient’s wishes, the
information was not included in a progress
note.
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Benefits of New Solution
• More succinct, clinically relevant, and factually correct
progress notes
• Notes will be available when you need them
• You will no longer have to print out notes
• Improved communication and coordination among
members of the healthcare team
• It will be easier to support appropriate levels of billing
• Notes will be configured to each specific service
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Impact of Current Practice
• Cost of unnecessary settlements
• Cost of legal fees
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Hoping and Waiting
Patient is admitted to the PACU after major
abdominal vascular repair. Pulses at the end of the
case are absent in both lower extremities. The
surgeon expects pulses will return in the immediate
post-operative period but does not document this or
document a clear follow up plan. Nursing and
surgical residents accept the patient’s absent pulses
as expected and do not call the attending when the
patient’s extremities deteriorate from lack of blood
flow. When the attending returns to see the patient
there is myonecrosis and bilateral amputation is
indicated. Family declines the procedure and patient
goes on to die.
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The Verbal Report
Patient’s AICD is turned off in the OR but not
documented. Verbal report is given to the PACU
that the AICD is off. RN questions resident who
says it’s OK to transfer the patient. Resident
says no problem as she is sure someone would
have told her if she needed to turn the AICD
back on. Patient is transferred to the floor and
sustains a V-tach arrest that is caught on
telemetry in a timely manner. The AICD had not
been turned back on.
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Note #1
Subjective/Objective
Subjective/Objective:
Pt states that he feels well. No SOB, states that he feels no pain in his leg, and has been
walking around with PT. O: no events overnight.
Gen: lying in bed, NAD
Pulm: coarse breath sounds, no crackles
CV: S1S2+, no M/R/G, irregularly irregular rhythm
Abd: soft, NT/ND, BS+
Ext: legs no longer edematous, erythema over RLE approximately same as yesterday.
Lab Results Section
Routine Hematology
9/18/2008 7:05
White Blood Cells
8.1
Nucleated RBCs
0
Red Blood Cells
2.71
Hemoglobin
8.7
Hematocrit
25.6
MCV
94.4
MCH
32.0
RDW
Platelets
MPV
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
Absolute Neutrophils
Absolute Lymphs
Absolute Monocytes
Absolute Eosinophils
Absolute Basophils
12.5
411
7.49
65
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5
1
5.3
1.4
0.9
0.4
0.1
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Note #1 (continued)
Assessment/Plan
Assessment/Plan:
90M h/o CHF, COPD (on home O2), HTN, CRI (baseline Cr 2.2-2.6), BPH,
hypothyroid, PAF, p/w RLE pain x1day. In ED, febrile to 102, in Afib with HR of
110. Pt received 500 cc NS bolus and IV dilt in ED, RLE found to be
edematous, swollen; likely cellulitis. LE duplex negative, BCx positive for
Acinetobacter in 2/2 bottles, sensitive to Unasyn, Cipro. Sputum Cx pos for
MRSA.
ID - cellulitis, Acinetobacter bacteremia
- leg improving slowly, seems to continue to improve off Abx
CV - CHF, PAF
- will continue to monitor I/O's, daily weights
- continuing Lasix 40 mg PO q12h
- continuing norvasc 5 mg daily
Pulm
- pt breathing well, will cont chest PT and nebs endo
- TSH normal, continuing synthroid at current dose
- continuing insulin sliding scale for hyperglycemia
- urine albumin:creatinine ratio elevated
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Note #1 (continued)
Assessment/Plan
GU
- continuing proscar, flomax
Heme
- anemia w/u consistent with iron deficiency, but anemia is macrocytic with
normal RDW; B12/folate normal, will give iron PO
- heme consulted, will f/u on recs for rest of MM/lymphoma workup as
outpt (BMBx)
PPx
- DVT: HSQ 5000 units Q8H
- on PPI, will attempt to determine why
dispo
- plan to D/C home with services on 9/19, tomorrow if okay with heme will attempt to reinstate
HHA today
- appreciate rehab consult recs
- full code.
Handwritten attending notes stated not iron deficiency
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Note #2
Interval History
No events overnight. No dyspnea. Ambulating.
Vital Signs
(input from ICIS)
Physical Exam:
Pulm: Unchanged from prior (Coarse BS)
Ext – Unchanged from prior (RLE erythema, no edema)
Labs:
Notable for normocytic anemia and thrombocytosis
Stable renal insufficiency
No other diagnositic tests
Rehab and Heme consults noted and appreciated. Heme eval to be completed
as an outpatient
Diagnosis/Problem/Plan
Cellulitis with Acinetobacter bactermia– better
Monitor off antibiotics; skin care
CHF Diastolic – acute-on-chronic – better
Continue furosemide 40mg PO q 12 hours
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Note #2 (continued)
Afib – unchanged
Rate controlled,
Anemia – acute – unchanged
Follow up with hematology as outpatient for further eval
COPD – chronic – unchanged
Continue O2 via nasal canula, chest PT
HTN – chronic - unchanged
Continue Norvasc
Chronic renal insufficiency – unchanged
Stable
Hypothryoidism – chronic – unchanged
Stable on current synthroid
Risk for DVT – acute – unchanged
Continue SC Heparin 5000U Q8
Goals towards discharge
Ambulatory on oral meds with home services in place
Progress toward meeting discharge goals
Awaiting home services
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Interval History is the first section of the
progress notes for attending MD, fellow
and medical student
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Hovering over
book icon will
display reference
of document,
date, time vital
sign values where
entered.
Automatically retrieves most recent vital
signs entered by nursing & others.
Looks back 48 hours, otherwise it’s blank.
You can enter vital signs taken by you.
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If there is no change from previous day, then
select “retrieve previous data”; text box will
auto populate with previous data
(if any) entered by AUTHOR.
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If Lab Results are reviewed, additional
selections display and becomes mandatory.
Comments text box also displays.
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Text box for Other Diagnostic comments
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Multiple selections allowed plus a
type in space for others.
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Text box automatically populates with previous
data entered by AUTHOR.
If worse, unchanged or better is selected, data
will persist until it is resolved or ruled out.
Plan is always blank. Selecting ‘Previous plan remains
the same’ will auto populate previous data (if any)
entered by AUTHOR.
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Displays 5 additional
diagnosis/problems/plans.
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Text boxes will be populated by most recent data
( if any) entered by AUTHOR .
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Attending MD’s progress note statement of
collaboration/supervision
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PROGRESS NOTES MEDICINE
Effective July 1, 2009, the Medicine Service will enter all progress notes in ICIS.
This initiative moves us closer to the goal of achieving a paperless environment and above all,
improving the quality of our documentation.
The structured progress note has been configured to each specific role for the Medicine Service (e.g.
an attending or fellow’s note will NOT have a hospital course entry whereas the resident/interns note will).
Eventually, other services progress notes will also be configured specifically to each service.
Please note that manual copy forward will be suppressed in the new progress note. To expedite note
completion, the system will copy forward predefined sections of the exam, problem list, and discharge
criteria.
It is highly recommended that you start the process of documenting care for the patient by viewing
documentation done by other clinicians the previous 24hrs (or greater), via the Clinical Summary Tab.
Selecting Physician View will display VS, Current Medications, Lab Results, Other Ancillary Results, Consult
Notes and Progress Notes. From the Progress Note tile, you have the option of viewing the content and or
enter a new note.
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