Professional Documents
Culture Documents
Note?
Omar S. Darwish, MS, DO
Hospitalist, Assistant Professor of Medicine
Department of Medicine
October 9, 2014
S
Objectives
S 55 yo man presents with shortness of breath x 2 days. At baseline has SOB with
exertion but he says now it is happening while at rest. He said 2 days ago while
watching TV he felt a sudden onset of SOB and broke out in a sweat. He denied
any fevers/chills. He says he has a cough and some wheezing but this hasn’t
changed for the past 2 years.
S The patient has a history of lung cancer diagnosed 2 years ago and his last
chemotherapy was 2 weeks ago. He denies any recent surgeries, calf pain, or history
of DVT or PE.
S Patient has a history of MI 2006 with 2 stents placed in the LAD and is taking
Aspirin 81, Coreg 6.25 bid, and simvastatin 20 mg po qday.
S ER course: afebrile, HR 94, BP 110/67, O2 sat 95% on RA, RR 22. patient had an
CXR which showed hyperinflated lung fields. He was given Solumedrol and
Ceftriaxone/Azithromycin, blood cultures were drawn.
Other parts of the History
S Don’t use the word “Consider” or state that you are going to do something if
something happens. E.g. If patient is unstable, will send to ICU. Avoid
nephrotoxins, consider increasing Metoprolol, Replete Lytes when needed
S Do assess your DVT risk as Low, Intermediate and High and if not on
anticoagulation give reasons why.
Assessment/Plan
S What do I mean?
S Don’t right a note just for the sake of writing a note
The note should reflect WHAT YOU DID THAT DAY AND
ONLY THAT DAY!!!
4 Areas
S Subjective
S Exam
S Date
S Assessment/Plan
Subjective
S Subjective
S Always ask a patient if they have pain and have them rate the
score.
Subjective: Don’t Write…
S This is not where you record that the patient didn’t like her
meal or the TV didn’t work, etc.
S Please Use It, but on your first progress note make it “real”
Robot
Real
S Gen: NAD, alert and oriented x 3
S Comfortable, sitting up in bed
S Vitals: BP 120/80, HR 80, RR 14, O2 SAT 99
S Vitals: BP 120/80, HR 80, RR 14, O2 SAT 99
S HEENT: NC/AT, PERRLA, EOMI
S CTAB and Breathing comfortably
S CV: RRR no m/r/g
S RRR
S Lungs: CTAB, no wheezing/rales/rhonchi
S Abd: soft, ND, less tender epigastric area
S Abdomen: mild TTP, ND,
S Ext: no edema, R peripheral line, no signs of
S Ext: no edema, no cyanosis infection
S Neuro: no focal deficits S GU: foley catheter, clear urine in foley bag
S Skin: no rashes
Data
S The formula:
S Symptom/Diagnosis, (IMPROVING,
WORSENING, OR UNCHANGED)
S If a Symptom, follow it with a differential diagnosis
(dd).
S The number of dd varies
S Your plan should include workup to support or
exclude a dd
Choose One…
S Toxic encephalopathy
S Metabolic Encephalopathy
S Drugs, e.g. Alcohol
S Fever
S Toxins/poisons
S Dehydration
S Medications (e.g. Dilantin overdose)
S Electrolyte imbalance
S Acidosis
S Infection (septic
encephalopathy)
S Organ failure (Uremia and
Hepatic)
Hypertension – Don’t get upset
S Archaic terms such as accelerated and malignant are used in the coding
world and they simply haven’t caught up with us.
S CC
I can’t breathe…
Don’t Write “Respiratory
Distress”
S Progress Notes
S Have 3 Levels of Coding
S To Get to Level 3 in a progress note INPATIENT you must
meet the following:
S 2 out 3 of the following
S Detailed History (C/C with 4 HPI elements, min 2 ROS)
S Detailed Exam (12 bullets)
S High Complexity Medical Decision Making
Decision Making
S Broken down into
S Problem Points
S Data Points
S Level of Risk
Problem Points
Data Points
Level of Risk, e.g High Risk
Assess Decision Making for
Each of These…
S A/P S A/P
S Don’t tell anyone what happened in the middle… Just tell them
the beginning and the end.
S Discharge Diagnosis:
S Acute Renal Failure 2nd dehydration form diarrhea
S Acute Diarrhea 2nd C. diff
S Hyponatremia Hypovolemia 2nd diarrhea
S Type II Diabetes c peripheral neuropathy
Hospital Course: 55 yo man presented with acute diarrhea and fond to have acute renal
failure with creatinine of 3. C.diff was + and patient started on Flagyl with clinical
improvement and IV hydration improved creatinine to 1.3.