written documentation skills i fall 2013- doctoring iii

7/29/2019 Written Documentation Skills I Fall 2013- Doctoring III

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Written Documentation

Part I

Steven Rougas, MD MS.MEd 14

Doctoring Year 2September 5, 2013


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Goals

What is a Medical Record? What are the basics ofWritten 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

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Logistics

1. Medical Record (5 min) 2. Written Documentation (10 min) 3. History and Physical (25 min)

4. SOAP Notes (5 min)

5. Doctoring Write-ups (5 min)3


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DISCLOSURES

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THE MEDICAL RECORD

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Written Documentation Skills

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

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

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Demographics Patient Name or

Identifier ** Date / Time / Writer Source / Reliability

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Subjective

What the patient tells you

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Subjective (S) CC HPI PMH SH FH ROS

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Chief Complaint (CC)I cant stop coughing

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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 iscurrently sick. She states the cough is intermittent throughout theday, worse at night. Nothing makes it better, but exerting herselfmakes it worse. She has never had a cough like this before andshe describes the cough as sharp. She produces white sputumwith her cough sometimes. She is concerned that she might havean infection and wants to feel better before her sisters weddingnext week. JS denies nausea, vomiting, diarrhea, fever, orabdominal pain.

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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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Family History (FH)Father: 50 (Type 2 Diabetes)Mother: 49 (Hypertension)Sister: 30 (Healthy)Children: NoneHistory of breast cancer on her fathers side of the

family

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Social History (SH) Patient works as a bank teller and reports happiness

with her job. She enjoys traveling with her friends andcurrently 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 anapartment currently and runs 1-2 miles per week.

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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


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

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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 accessorymuscles. Percussion resonant throughout. Auscultation reveals fine crackles in the

RLL otherwise clear. Labs: Troponin < 0.15 WBC: 6 Platelets: 300 ChestXray: No acute cardiopulmonary process

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Assessment

What you think is going on

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Assessment Formulation Differential Diagnosis

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Formulation Statement34 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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Differential DiagnosisPneumonia vs. viral upper respiratory illness vs.

pulmonary embolism

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Plan

What you are going to do

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Plan Diagnostic Tests Treatments Referrals Patient Education Follow-up

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Tabular Will send patient for an

outpatient chest xray today.

Start Tessalon Pearls 100 mgPO twice daily for cough.

Will obtain blood work today inthe office including CBC andchemistry panel

If chest xray today reveals focalpneumonia, I will begin thepatient on Levofloxacin 750 mgPO once daily for five days.

Patient will return in 5 days for are-evaluation in the office beforeher sisters wedding.

Problem-based Cardiac Pulmonary GI Endocrine SkinNeurologic

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Closing

Make it official

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Sign Date Time Contact

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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 , welldeveloped

No acute distress Well-appearing vs.

ill-appearing

Younger vs. olderthan 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 nailsNo petechiae, striae, orecchymoses

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HEENT

Head: Normocephalic, atraumatic (NCAT) Eyes: Conjunctiva clear, sclera non-icteric, no proptosis orlid 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 membranestranslucent, with normal architecture, no erythema, dullness, orbulging. Hears finger rub. (TM)

Nose: Septum in midline, mucosa pink with no discharge, non-tender over frontal and maxillary sinuses. (NT)

Throat / Mouth: Mucous membranes moist, tonsils withouterythema or exudate. Uvula midline. Good dentition. (MMM)

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Neck

Supple. Full range ofmotion.

Trachea midline. Thyroid palpable:

small, smooth,

nontender, no masses.

Lymph nodes notpalpable bilaterally.

FROM

NT

LAD

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Cardiovascular

No jugular venous distention Point of maximal impulse at the

5th intercostal space in the mid-clavicular line, well localized.

No heaves, lifts, or thrills. Regular rate and rhythm. S1 normal intensity, A2>P2,

physiological splitting.

No murmurs, rubs, or gallops.

JVD PMI

RRR

m/r/g

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Cardiovascular

Nocarotid bruits. Pulses are 2+ and symmetric

bilaterally in the carotid,brachial, radial, femoral,popliteal, posterior tibial anddorsalis pedis regions.

Capillary refill less than 2seconds.

No lower extremity edema.

PT, DP

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Pulmonary

Breathing appears unlabored withno use of accessory muscles.

Thorax symmetrical, no increasedantero-posterior diameter. Equalexpansion.

No chest wall tenderness topalpation. Tactile fremitussymmetric. 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, ordistended

Note any scars Normoactive bowel sounds in all 4

quadrants, no renal or aortic bruits

Tympanic to percussion in all 4quadrants, no shifting dullness

Soft, non-tender, non-distended, nopulsatile mass, nohepatosplenomegaly

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 oruncircumcised

Testes descended, non-tender to palpation,without masses

No scrotal masses oringuinal hernias

TTP

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Genital/Pelvic

Female

Normal external genitalia Cervix clean and smooth Uterus anteverted. No

cervical motion tenderness

Adnexae non-tenderwithout masses

Cx CMT NT

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Musculoskeletal

Full range of motion inshoulders, elbows,

wrists, hands, hips,knees, ankles, and feet

(active vs. passive)

No redness, swelling, ortenderness of any joints

FROM

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Neurological

Cranial nerves: II-XIIsymmetric and intact

Motor: 5/5 motor strengthin all four extremities

Sensory: Sensationgrossly intact. Responses

to pain, light touch,pinprick, position, andvibration within normallimits.

CN

WNL

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Neurological

Cerebellar: Finger-to-nose andheel-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 walkis 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

person, time, and place

Appropriate, normalaffect

A & O x 3

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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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SOAP

S: Subjective O: Objective A: Assessment P: Plan

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CC, HPI, PMH, FH,SH, RO

PE, labs, imaging Formulation or DDx Tabular or problem-

based


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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

PrescriptionReflection

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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 ofWritten 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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written documentation skills i fall 2013- doctoring iii

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