Transcript Basics of Writing Notes

Outline

The Patient Chart

Admission Note (History and Physical)

Progress Notes

Discharge Notes

Operative Notes
 Pre and post-operative
 Procedure notes
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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
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 !
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
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
H+P Components

Chief complaint

Social History

History of Present

Family History
Illness

Review of Systems

Past Medical History

Physical Exam

Past Surgical History

Labs/Studies

Allergies

Assessment and Plan

Medications
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
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 ……
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
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.
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
Other Components

Medications:

 Dosage and duration
Social history:
 Occupation
 Does patient take the
 Tobacco, alcohol or illicit
medications?
drug use
 Over the counter and herbal
 Marital and children status
medications

Allergies:
 Record allergies and reactions
to medications, foods and latex
 No known drug allergies

Family History:
 Include inherited diseases
 Ex: + Diabetes in mother and
sister
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
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 !
Labs and Radiographic Studies

Admission labs and important studies

Example:
 Complete blood count
 Chemistry panel
 Cardiac enzymes
 EKG
 Chest X-ray
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
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
Example
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.
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
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
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
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)
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 ….
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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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
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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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
Pre-Operative Note Format

Date and time

Pre-op diagnosis: Appendicitis

Procedure: Open
Appendectomy



CXR: No active disease (note the
findings)

EKG: Normal sinus rhythm (note any
abnormalities)

Pre-op Orders: Nothing Per Oral
Blood: Typed and crossed for 2 units
of O+
(NPO)

Consent: Singed on chart
Labs: CBC, PT/PTT (record

Anesthesia: To see patient, or
results prior to the procedure)
patient seen, note on chart
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
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
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
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
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
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
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
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
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)
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?
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?
Any Questions ??
References

Maxwell Quick Reference Book. 2006.