Written Documentation Part I

Steven Rougas, MD MS.MEd 14 Doctoring Year 2 September 5, 2013

Goals
What is a Medical Record? What are the basics of Written Documentation? How do I write a full History and Physical? How do I write a progress note (SOAP)?

Practice a complete written history and physical Review expectations of case write-ups in Doctoring

Logistics
1. Medical Record 2. Written Documentation 3. History and Physical 4. SOAP Notes 5. Doctoring Write-ups (5 min) (10 min) (25 min) (5 min) (5 min)
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DISCLOSURES

THE MEDICAL RECORD

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Written Documentation Skills

Required reading with overview, template, and sample H&Ps.

The Medical Record

Medical Record Case Write-Up Legal document Ownership Not written = not done Written but not done = FRAUD
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The Medical Record

Purpose
Patient Care Delivery Manage Risk Billing & Reimbursement Education Regulation Research

Content
Identification Info Health History Medical Exam Findings Test Results Medications/Rx Referrals Problem List
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WRITTEN DOCUMENTATION
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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report

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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report

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Written Documentation
Demographics
Patient Name or Identifier ** Date / Time / Writer Source / Reliability

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Subjective
What the patient tells you

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Written Documentation
Subjective (S)
CC HPI PMH SH FH ROS

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Written Documentation
Chief Complaint (CC)
I cant stop coughing

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Written Documentation
History of Present Illness (HPI)
JS is a 34 year old female with no significant PMH who presents with 1 week of a productive cough. The patient recently traveled to Costa Rica with friends and noticed the cough. No one else is currently sick. She states the cough is intermittent throughout the day, worse at night. Nothing makes it better, but exerting herself makes it worse. She has never had a cough like this before and she describes the cough as sharp. She produces white sputum with her cough sometimes. She is concerned that she might have an infection and wants to feel better before her sisters wedding next week. JS denies nausea, vomiting, diarrhea, fever, or abdominal pain.

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Written Documentation
Past Medical History (PMH)
Childhood Illnesses: Multiple ear infections Adult Illnesses: None Hospitalizations: None Surgical History: Tonsils and Adenoids Removed, 1985 Medications: None Allergies: Penicillin (rash)

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Written Documentation
Family History (FH)
Father: 50 (Type 2 Diabetes) Mother: 49 (Hypertension) Sister: 30 (Healthy) Children: None History of breast cancer on her fathers side of the family

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Written Documentation
Social History (SH)
Patient works as a bank teller and reports happiness with her job. She enjoys traveling with her friends and currently denies financial or life stressors. She is not sexually active and is currently not in a relationship. She drinks 1-2 glasses of wine per week socially, but denies tobacco or illicit drug use. She lives alone in an apartment currently and runs 1-2 miles per week.

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Written Documentation
Review of Systems (ROS)
General: Patient denies fever, chills, night sweats, weight loss. Skin: Denies rash or new lesions. HEENT: Denies nose bleeds, sore throat, neck pain. Neck: Denies lumps, or stiffness. Cardiac: Denies chest pain, irregular heartbeat. Pulmonary: See HPI; denies, wheezing, hemoptysis, and pleuritic pain. GI: Denies vomiting, constipation, diarrhea, change in bowel habits, rectal bleeding or jaundice. Genitourinary: Denies dysuria, nocturia, hematuria, incontinence, or groin pain. Musculoskeletal: Denies, joint swelling, stiffness. Neurologic: Denies headaches, numbness, weakness, difficulty walking, tremors Heme/immunology: Denies easy bruising, excessive bleeding, anemia, frequent infections. Psychiatric: Denies suicidal/homicidal thoughts, difficulty concentrating, or feeling down.

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Objective
What you observe about the patient

Written Documentation
Objective (O)
Vitals General Appearance Physical Exam Laboratory Tests Diagnostic Tests

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Written Documentation
General : Well appearing female, appears stated age, comfortable, awake, alert. Vital Signs: Heart rate: 88 (regular) Temp 97.8F Weight 130lbs Height 58 BP supine, L arm, 130/80, reg cuff BP sitting, R arm, 125/85, reg cuff Skin: No rash. Normal skin turgor. Cardiovascular: PMI 5th intercostal space, midclavicular line, well localized, no heaves, thrills. S1 normal intensity, A2>P2 with physiologic splitting. No gallops, clicks, murmurs or rubs. Capillary refill 3 seconds in bilateral hands. Pulses are 2+ and symmetric in the bilateral brachial, radial, femoral, and dorsalis pedis pulses. Pulmonary: Thorax symmetric, no increased A-P diameter, no use of accessory muscles. Percussion resonant throughout. Auscultation reveals fine crackles in the RLL otherwise clear. Labs: Troponin < 0.15 WBC: 6 Platelets: 300 Chest Xray: No acute cardiopulmonary process

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Assessment
What you think is going on

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Written Documentation
Assessment
Formulation Differential Diagnosis

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Written Documentation
Formulation Statement
34 yr old female with no significant PMH who presents with 1 week of a productive, sharp cough without associated fever after traveling to Costa Rica with fine crackles in the RLL on exam, likely representing acute community acquired pneumonia.

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Written Documentation
Differential Diagnosis
Pneumonia vs. viral upper respiratory illness vs. pulmonary embolism

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Plan
What you are going to do

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Written Documentation
Plan
Diagnostic Tests Treatments Referrals Patient Education Follow-up

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Written Documentation
Tabular
Will send patient for an outpatient chest xray today. Start Tessalon Pearls 100 mg PO twice daily for cough. Will obtain blood work today in the office including CBC and chemistry panel If chest xray today reveals focal pneumonia, I will begin the patient on Levofloxacin 750 mg PO once daily for five days. Patient will return in 5 days for a re-evaluation in the office before her sisters wedding.

Problem-based
Cardiac Pulmonary GI Endocrine Skin Neurologic

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Closing
Make it official

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Written Documentation
Sign Date Time Contact

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Written Documentation
Addendums Corrections

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HISTORY & PHYSICAL

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History & Physical

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History & Physical

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History Writing Exercise

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History & Physical

CC HPI PMH FH SH ROS
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History & Physical

General appearance Vitals Skin HEENT Neck Cardiovascular Pulmonary Abdomen Rectal Genital Musculoskeletal Neurological Psychiatric Mini-mental status exam
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General Appearance
Well nourished , well developed No acute distress Well-appearing vs. ill-appearing Younger vs. older than stated age Tearful, comfortable WN, WD NAD

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General Appearance

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Vitals
Height Weight Body Mass Index Blood Pressure Pulse Respiratory Rate Pulse Oximetry Visual acuity Hearing
Ht Wt BMI BP HR RR Pulse Ox

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Skin
Observe color Observe for dryness No rashes or unusual moles Normal hair and nails No petechiae, striae, or ecchymoses

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HEENT
Head: Normocephalic, atraumatic (NCAT) Eyes: Conjunctiva clear, sclera non-icteric, no proptosis or lid lag; pupils equal, round, respond normally to light and accommodation, extraocular movements intact, full visual fields to confrontation. Fundi: A:V ratio 2:3, no A-V nicking, no hemorrhages or exudates; disc margins sharp without papilledema. (PERRLA, EOMI)

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HEENT
Ears: External auditory canals clear; tympanic membranes translucent, with normal architecture, no erythema, dullness, or bulging. Hears finger rub. (TM) Nose: Septum in midline, mucosa pink with no discharge, nontender over frontal and maxillary sinuses. (NT) Throat / Mouth: Mucous membranes moist, tonsils without erythema or exudate. Uvula midline. Good dentition. (MMM)

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Neck
Supple. Full range of motion. Trachea midline. Thyroid palpable: small, smooth, nontender, no masses. Lymph nodes not palpable bilaterally. FROM

NT

LAD

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Cardiovascular
No jugular venous distention Point of maximal impulse at the 5th intercostal space in the midclavicular line, well localized. No heaves, lifts, or thrills. Regular rate and rhythm. S1 normal intensity, A2>P2, physiological splitting. No murmurs, rubs, or gallops.
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JVD PMI RRR

m/r/g

Cardiovascular
No carotid bruits. Pulses are 2+ and symmetric bilaterally in the carotid, brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis regions. Capillary refill less than 2 seconds. No lower extremity edema.

PT, DP

LE

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Pulmonary
Breathing appears unlabored with no use of accessory muscles. Thorax symmetrical, no increased antero-posterior diameter. Equal expansion. No chest wall tenderness to palpation. Tactile fremitus symmetric. Resonant to percussion. Clear to auscultation bilaterally. No rhonchi, rales (aka crackles), wheezes, or rubs.

AP TTP

CTAB

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Breast
Symmetrical No nipple discharge No dominant masses No axillary adenopathy

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Abdomen
Observe if flat, protuberant, or distended Note any scars Normoactive bowel sounds in all 4 quadrants, no renal or aortic bruits Tympanic to percussion in all 4 quadrants, no shifting dullness Soft, non-tender, non-distended, no pulsatile mass, no hepatosplenomegaly No costo-vertebral angle tenderness

NABS

NT, ND, HSM CVA

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Rectal
No hemorrhoids or fissures Normal tone Prostate not enlarged or tender to palpation No masses Stool is soft, brown, guaiac negative

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Genitourinary
Male Circumcised or uncircumcised Testes descended, nontender to palpation, without masses No scrotal masses or inguinal hernias
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TTP

Genital/Pelvic
Female Normal external genitalia Cervix clean and smooth Uterus anteverted. No cervical motion tenderness Adnexae non-tender without masses

Cx CMT NT

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Musculoskeletal
Full range of motion in shoulders, elbows, wrists, hands, hips, knees, ankles, and feet (active vs. passive) No redness, swelling, or tenderness of any joints

FROM

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Neurological
Cranial nerves: II-XII symmetric and intact Motor: 5/5 motor strength in all four extremities Sensory: Sensation grossly intact. Responses to pain, light touch, pinprick, position, and vibration within normal limits. CN

WNL

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Neurological
Cerebellar: Finger-to-nose and heel-to-shin within normal limits. Alternating hand motion intact. Reflexes: 2+ reflexes (biceps, triceps, brachioradialis, patellar, achilles) bilaterally. Flexor plantar response. Gait: Toe, heel, and tandem walk is within normal limits. Able to stand from chair without using hands.

WNL

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Psychiatric
Folstein MMSE 30/30 Alert and oriented to A & O x 3 person, time, and place Appropriate, normal affect

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Complete Physical Writing Exercise

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History & Physical

General appearance Vitals Skin HEENT Neck Cardiovascular Pulmonary Abdomen Rectal Genital Musculoskeletal Neurological Psychiatric Mini-mental status exam
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SOAP NOTES
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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report

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SOAP
S: Subjective O: Objective A: Assessment P: Plan CC, HPI, PMH, FH, SH, RO PE, labs, imaging Formulation or DDx Tabular or problembased
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SOAP Notes
S: Subjective O: Objective A: Assessment P: Plan

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DOCTORING WRITE-UPS
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Doctoring Write-Ups
Mentor sites Authorship Faculty Professionalism Case Write-Up Prescription Reflection

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Doctoring Write-Ups

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TOP TEN
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10. Never Use Patient Name

Initials are your friend

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9. Dont forget the CC

Use quotes

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8. Dont bore your reader

Balance thorough with succinct

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7. Incomplete history
Gather everything

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6. Disorganized ROS
Negative for what?

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5. No vital signs
They are vital for a reason!

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4. Incomplete PE
Be as complete as possible

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3. Redundancy
Say it once, right

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2. Disorganized PE
Head to toe

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1. No reflection or prescription
Reflect, prescribe, and prosper

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QUIZ!
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1. In the Doctoring course, case write-ups should include what 3 components?

History & Physical Prescription Reflection
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2. When I need help with writing case write-ups, what documents are available for help?
Written Documentation Skills Complete PE Answer Key Excellent Case Write-Up Examples
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3. How do I know which abbreviations to use in my case write-ups?

CANVAS Written Documentation Abbreviations
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Goals - Accomplished
I know what a Medical Record is I know the basics of Written Documentation I have written a full History and Physical I have an example of a progress note (SOAP)

I Practiced a complete written history and physical I know the expectations of case write-ups in Doctoring

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Reminders
First Case Write-Up Due: Sunday, 9/8/13 6pm Bring a mentor case next week to class for OP Next week, start in small groups Professional attire

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