Documentation The other cornerstone of Western medicine.

DocumentationDocumentation

The The other other cornerstone ofcornerstone of

Western medicineWestern medicine

Initial thoughts. . .Initial thoughts. . .

Documentation is Documentation is essential essential to providing to providing skilled medical care. . . skilled medical care. . .

Serves a variety of purposes:Serves a variety of purposes: Provides written record of presentation, Provides written record of presentation,

evaluation, and treatment – to be reviewed by evaluation, and treatment – to be reviewed by oneself or by consultantsoneself or by consultants

Allows for formal chart review of appropriate Allows for formal chart review of appropriate care and documentation – “peer review”care and documentation – “peer review”

Provides written proof of patient consent, Provides written proof of patient consent, medication instructions, etc.medication instructions, etc.

Directs support staff in the care of the patientDirects support staff in the care of the patient

Peer ReviewPeer Review A formal evaluation of a certain A formal evaluation of a certain

percentage of a physician’s workpercentage of a physician’s work Performed on a regular basis at Performed on a regular basis at

almost all U.S. medical institutionsalmost all U.S. medical institutions A physician’s peers review outpatient A physician’s peers review outpatient

and inpatient records for clarity, and inpatient records for clarity, accuracy, appropriate accuracy, appropriate documentation, and provision of documentation, and provision of standard of care medicine. standard of care medicine.

So, what exactly do So, what exactly do physicians document?physicians document?

Patient care related documentationPatient care related documentation The “Notes”The “Notes” Admission and DischargeAdmission and Discharge The “Orders”The “Orders” Legal Documentation and ConsentLegal Documentation and Consent

Administrative DocumentationAdministrative Documentation Routine admission, disposition formsRoutine admission, disposition forms Birth and Death certificatesBirth and Death certificates Insurance or billing paperworkInsurance or billing paperwork

The NotesThe Notes An abbreviated notation of the facts – An abbreviated notation of the facts –

similar to the “notes” one might take similar to the “notes” one might take during a lecture and refer to while during a lecture and refer to while studying before a teststudying before a test

Allows colleagues and other medical Allows colleagues and other medical personnel a chance to review the case personnel a chance to review the case

Allows oneself a chance to review initial Allows oneself a chance to review initial presentation and evaluationpresentation and evaluation In later review of the chart one often finds In later review of the chart one often finds

subtle areas previously left unexploredsubtle areas previously left unexplored

The NotesThe Notes In addition to recording In addition to recording SubjectiveSubjective and and

ObjectiveObjective portions of the patient portions of the patient presentation, documentation allows the presentation, documentation allows the physician to convey his or her own physician to convey his or her own thoughts on the case – this is done in the thoughts on the case – this is done in the Assessment Assessment portion of the noteportion of the note

Next, the physician documents their Next, the physician documents their PlanPlan for further diagnostic study and/or for further diagnostic study and/or treatmenttreatment

The NotesThe Notes Careful attention is paid to internal Careful attention is paid to internal consistencyconsistency

It It is notis not necessary to explain every single necessary to explain every single laboratory test or treatment modality in detaillaboratory test or treatment modality in detail It It isis necessary to provide ample facts such necessary to provide ample facts such that any competent physician would be able to that any competent physician would be able to easily deduce your reasoningeasily deduce your reasoning

Finally, the fact that you discussed Finally, the fact that you discussed your your thinking, the plan, and the expected thinking, the plan, and the expected outcome with your patient is documentedoutcome with your patient is documented

Ms. Fukai, a 23 y/o o/w healthy Japanese ♀, presented today for ℅ acute onset R ear pain following dailyswimming in the local pool over the previous week. Pt. has exp’d 36 hrs ↑’ing R otalgia assoc. w/ ↑’ing mucoidd/c. Afebrile and w/o any signs or symptoms of illness. Denies trauma/diving.

Meds: Eucerin, occasional topical hydrocortisone 2% ointmentAllergy: NKDA PMH/PSH/FH: Atopic dermatitis well controlled on current tx. o/w N/CSoc Hx: No tobacco, occasional EtOH (<2 drinks per week)

VS’s: T=37°C, P=68, RR=12, BP=120/64GEN: Alert, NADHEENT: PERRLA/EOMI – B Nares patent/NL turbinates, L TM Θ with + movement to insufflation,

R TM partially visualized and mobile to insufflation with + mucoid otorrhea in canal, + painon manipulation of right pinnae, neck supple/Θ lymphadenopathy

LUNGS: CTABCV: RRR without M/R/G NL S1/S2SKIN: Warm, moist – Ø evidence of atopic Δ’s Dx: Otitis Externa 2° to excessive H2O exposure

Plan: Ofloxacin otic – 6-8 drops AD TID X 7 days

Avoid H2O exposure throughout duration of tx

RTC if discharge/pain ↑’s, swelling of neck/face, no response to tx

Discussed etiology, pathophysiology, medication use, f/uPatient expresses understanding and concurrence

Andrew W. Schiemel, MD, FAAP

Shorthand from previous slideShorthand from previous slidey/o = years oldo/w = otherwise♀ = female℅ = complaint ofR = rightexp’d = experiencedhrs = hours↑’ing = increasingassoc = associatedw/ = withd/c = dischargew/o = withoutNKDA = no known drug allergiestx = treatmentN/C = non-contributoryEtOH = alcoholNAD = no acute distressPERRLA = pupils equal round and reactive to light

and acc.EOMI = extra ocular movement intact

Shorthand continuedShorthand continuedB = bilateralL = leftTM = tympanic membraneΘ = negative+ = positiveCTAB = clear to auscultation bilaterallyRRR = regular rate and rhythmM/R/G = murmur, rub, gallopNL = normalS1/S2 = first and second heart soundsØ = no (none)Δ’s = changesDx = diagnosis2° = secondaryH2O = waterAD = aure dextra (right ear)TID = three times per dayX = for (X 7 days = for seven days)RTC = return to clinic↑’s = increasesf/u = follow up

Review of sample noteReview of sample note Clearly explains the patient’s presentation and Clearly explains the patient’s presentation and

makes reference to the patient’s overall makes reference to the patient’s overall health/medication use, etc. health/medication use, etc.

Pertinent positive and negative historical and Pertinent positive and negative historical and physical facts are included.physical facts are included.

Although sufficient information to rule-out every Although sufficient information to rule-out every known cause of otorrhea is not included, one known cause of otorrhea is not included, one can adequately discern between the two main can adequately discern between the two main diagnostic possibilities (otitis externa or ruptured diagnostic possibilities (otitis externa or ruptured tympanic membrane) with the information tympanic membrane) with the information provided.provided.

Review of sample noteReview of sample note

Working diagnosis and treatment plan are clearly and Working diagnosis and treatment plan are clearly and succinctly laid outsuccinctly laid out

Exact medication directions are recorded, including Exact medication directions are recorded, including dose, route, frequency, and duration of therapy. dose, route, frequency, and duration of therapy.

Indications for returning to the clinic are addressed Indications for returning to the clinic are addressed and the physician notes that the patient expresses and the physician notes that the patient expresses understanding and acceptance of the plan. understanding and acceptance of the plan.

Finally, the chart entry is signed and dated – with the Finally, the chart entry is signed and dated – with the physician’s printed name provided for accuracy.physician’s printed name provided for accuracy.

Admission and DischargeAdmission and Discharge

Admission H&P’s and discharge summaries Admission H&P’s and discharge summaries are perhaps the most tedious of all are perhaps the most tedious of all medical documentation. medical documentation.

Standard pre-printed forms for each are in Standard pre-printed forms for each are in common use so that important details are common use so that important details are not overlooked. not overlooked.

The assessment portion affords the The assessment portion affords the physician the opportunity to express the physician the opportunity to express the logic effecting specific decisions. logic effecting specific decisions.


The The assessmentassessment is often written as a narrative. is often written as a narrative. The physician may report competing diagnoses, The physician may report competing diagnoses,

concerns regarding reliability of diagnostic testing or concerns regarding reliability of diagnostic testing or treatment side effects, anticipated outcome, etc. treatment side effects, anticipated outcome, etc.

The The planplan portion of the admission paperwork portion of the admission paperwork typically lays out a variety of diagnostic and typically lays out a variety of diagnostic and treatment actions. treatment actions. Essentially, it is a list of tasks to be accomplished Essentially, it is a list of tasks to be accomplished

during the admission. during the admission. One should include “indications for discharge” in One should include “indications for discharge” in

every admission plan. every admission plan.


The The discharge summarydischarge summary is simply a well-organized is simply a well-organized running dialogue that delineates the patient’s running dialogue that delineates the patient’s presentation, hospital stay, and condition on presentation, hospital stay, and condition on dischargedischarge

First, details regarding the initial presentation First, details regarding the initial presentation are summarizedare summarized Strict Strict delineation ofdelineation of subjective subjective opinionsopinions fromfrom

objective objective factsfacts is often overlooked is often overlooked

Instead, the key here is to summarize the basics of Instead, the key here is to summarize the basics of the presentation so that anyone reading the the presentation so that anyone reading the discharge summary understands how you arrived at discharge summary understands how you arrived at your admitting diagnosisyour admitting diagnosis

Admission and DischargeAdmission and Discharge Secondly, the physician outlines the Secondly, the physician outlines the

patient’s hospital stay, remarking on patient’s hospital stay, remarking on general trends observed from day to day – general trends observed from day to day – hopefully ending in resolution of disease or hopefully ending in resolution of disease or significant improvement.significant improvement.

If, for example, the patient was steadily If, for example, the patient was steadily weaned from supplemental oxygen, there weaned from supplemental oxygen, there is no reason to list out a variety of pulse is no reason to list out a variety of pulse oximetry readings and subsequent oximetry readings and subsequent changes to oxygen delivery. changes to oxygen delivery.

Admission and DischargeAdmission and Discharge Instead the physician simply states:Instead the physician simply states:

““Throughout the admission, supplemental Throughout the admission, supplemental oxygen initially supplied at 10LPM via non-oxygen initially supplied at 10LPM via non-rebreather face mask - was weaned entirely. rebreather face mask - was weaned entirely. At discharge the patient was consistently At discharge the patient was consistently saturating >98% via pulse oximetry on room saturating >98% via pulse oximetry on room air alone.”air alone.”

The Orders The Orders Physician orders are written instructions Physician orders are written instructions

for patient care. for patient care.

Historically the physician’s orders were Historically the physician’s orders were written using medical shorthand in an written using medical shorthand in an effort to save time. effort to save time.

Recently, however, there has been a push Recently, however, there has been a push to revise this system and allow for minimal to revise this system and allow for minimal abbreviation use due to concerns abbreviation use due to concerns regarding medication and treatment regarding medication and treatment errors. errors.

The Orders The Orders Inpatient charting involves two varieties of Inpatient charting involves two varieties of

medical orders – admission or transfer medical orders – admission or transfer orders and daily orders. orders and daily orders.

In an effort to remember all the specifics of In an effort to remember all the specifics of admission orders, students and junior staff alike admission orders, students and junior staff alike use the acronym, ADCVAANDIMLS use the acronym, ADCVAANDIMLS

pronounced “A-D-C van Dim-els” pronounced “A-D-C van Dim-els”

The Orders The Orders

Admit to – Physician notes the specific location within the hospital where the patient should be admitted

Diagnosis – The working diagnosis or diagnosis to be excluded

Condition – One word reference to the patient’s general condition – e.g. Good/stable/guarded or poor/fair/critical

Vital signs – Frequency of vital signs is listed - to include mention of any continuous monitoring such as cardiorespiratory monitor (CRM) – standard

orders involve “q shift” or “every shift” vital signs – indicating that they are to be taken at

change of the nursing shift

Allergies – Patient medication allergies are listed (if none, no known drug allergies (NKDA) is listed


Activity – Allowable patient activity is listed here (e.g. bed rest, bed rest with bathroom privileges, normal activity, limited activity, etc.)

Nursing – Any specific nursing instructions (e.g. change patient position every 4 hours to avoid bed sores, sponge bath every morning, record fluid intake and output (strict I/O’s), indications to call on-duty physician such as “call medical officer for temperature greater than 39.5 degrees,” etc.)

Diet – Allowable diet for patient (e.g. nothing by mouth (NPO), clear liquids (no solids), full liquids, soft diet, soft mechanical, regular, American Dietary Association 2000 calorie diet (ADA 2000), low-sodium, low protein, lactose restricted, etc.)


IV fluids – Standard orders for intravenous (IV) fluids are listed here; although every admission does not involve IV fluid administration, this section allows for a dedicated space to indicate such therapy. Attention should be paid to details regarding the fluid composition, the volume to be given and the rate at which the fluids are to be run.

Medications – Standing medication orders – that is, medication to be taken on a recurring basis throughout the admission; be sure to mention dosage, frequency, route, and indication where appropriate (e.g. acetaminophen 500 milligrams by mouth every 8 hours as needed for fever)


Labs – This includes laboratory or radiological studies to be ordered at the time of admission and/or any recurrent lab/rad orders

(e.g. 1. Acute abdominal series at admission, 2. CBC with differential count every morning, etc.)

Special – Any orders that are non-medical in nature (e.g. patient may have off-ward privileges during the day. Or perhaps,

patient does not want any visitors)

The OrdersThe Orders

• Transfer orders follow this same format, however the orders begin with “Transfer to ______” instead of “Admit to _____.”

As the patient is being sent to an entirely different section of the hospital, all orders must be re-written.

Simply writing a one-line order for “Transfer patient to ______” is not sufficient.

Legal DocumentationLegal Documentation

Remember, the entire chart is a legal document – Remember, the entire chart is a legal document – this is this is notnot only the physician’s personal record of only the physician’s personal record of patient care – it is patient care – it is also also available for perusal by available for perusal by the ancillary staff, the patient, the ancillary staff, the patient, or the patient’s or the patient’s lawyer!lawyer!

Written consent for invasive procedures or Written consent for invasive procedures or experimental/chemotherapeutic medication use is experimental/chemotherapeutic medication use is commonplace in Western medicinecommonplace in Western medicine

Forms document specific discussion regarding Forms document specific discussion regarding indication, procedural or treatment plan, and possible indication, procedural or treatment plan, and possible complicationscomplications


Verbiage is included that indicates the patient’s Verbiage is included that indicates the patient’s understanding of these issues as well as a willingness to understanding of these issues as well as a willingness to undergo the planned procedure or therapyundergo the planned procedure or therapy

This form is then signed and dated by both patient and This form is then signed and dated by both patient and physicianphysician

Additionally, a witness to the patient’s signature and Additionally, a witness to the patient’s signature and verbal agreement is present and signs the formverbal agreement is present and signs the form

This person should not be a direct member of the team which will This person should not be a direct member of the team which will perform the procedure or treatment perform the procedure or treatment


Operation reports and procedural notes are Operation reports and procedural notes are another form of legal documentationanother form of legal documentation

The specifics of the procedure or operation are The specifics of the procedure or operation are documented in painstaking detail with reference to documented in painstaking detail with reference to prepping, draping, sterile technique, and the likeprepping, draping, sterile technique, and the like

Finally both anticipated results and unanticipated Finally both anticipated results and unanticipated complications are addressedcomplications are addressed

For example, a procedural note for lumbar For example, a procedural note for lumbar puncture in a 1-month-old infant might look like puncture in a 1-month-old infant might look like this:this:

Written consent was obtained and all aspects of the procedure were discussed at length with the family to include indication, procedural technique, and possible complications. The infant was prepped and draped in sterile fashion and sterile technique was followed throughout. A 24 gauge spinal needle was introduced into the spinal canal at the L3/L4 intervertebral space using standard accepted technique – only one attempt was necessary to obtain cerebrospinal fluid (CSF) sample. Approximately 8 ml of CSF was obtained and sent for standard chemistries, cell count, gram stain and culture. Skin site was cleaned and sterile dressing was applied. Infant tolerated the procedure well. There was no blood loss or complication.

Lumbar Puncture Lumbar Puncture ConsentConsent

Legal DocumentationLegal Documentation Some legal documentation serves only to avoid Some legal documentation serves only to avoid

potential litigation and has no medical purpose – One potential litigation and has no medical purpose – One such example is the documentation of a patient leaving such example is the documentation of a patient leaving against medical adviceagainst medical advice

This process of self-removal from the inpatient hospital This process of self-removal from the inpatient hospital environment is referred to as “leaving against medical environment is referred to as “leaving against medical advice” or simply AMAadvice” or simply AMA

Patients who wish to leave the hospital against the Patients who wish to leave the hospital against the physician’s wishes are asked to sign a form that clearly physician’s wishes are asked to sign a form that clearly states the samestates the same

This documentation attempts to lessen the likelihood of This documentation attempts to lessen the likelihood of litigation against the physician or hospital should the litigation against the physician or hospital should the patient suffer a bad outcome as a result of early patient suffer a bad outcome as a result of early dischargedischarge

Administrative Administrative documentationdocumentation

Purely administrative forms include routine Purely administrative forms include routine paperwork associated with admission, transfer or paperwork associated with admission, transfer or dispositiondisposition

Additionally, completion of birth and death Additionally, completion of birth and death certificates, as well as insurance forms, can be certificates, as well as insurance forms, can be considered mostly administrative tasksconsidered mostly administrative tasks Typically these forms will require only the physician’s Typically these forms will require only the physician’s

signature, as the details will have been filled in signature, as the details will have been filled in previously by the administrative support staffpreviously by the administrative support staff

Needless to say, as in any situation where your signature Needless to say, as in any situation where your signature certifies acceptance of whatever it is you are signing, it is certifies acceptance of whatever it is you are signing, it is important to review the information on the form for important to review the information on the form for accuracy accuracy before signingbefore signing

Basic Tenets of Basic Tenets of DocumentationDocumentation

Pay attention to prosePay attention to prose The most basic requirement of medical The most basic requirement of medical

documentation is not dissimilar to the basics of any documentation is not dissimilar to the basics of any effective writing –penmanship, word choice, and effective writing –penmanship, word choice, and grammar are of paramount importancegrammar are of paramount importance

In documenting the patient encounter, one must In documenting the patient encounter, one must ensure that the text is legible – an unintelligible entry ensure that the text is legible – an unintelligible entry is uselessis useless

Unlike oral presentation, written documentation Unlike oral presentation, written documentation allows for (and encourages) the use of acronyms and allows for (and encourages) the use of acronyms and abbreviationsabbreviations

Nonetheless, a physician’s written assessment should Nonetheless, a physician’s written assessment should

reflect a sharp medical intellect and a graceful reflect a sharp medical intellect and a graceful literary styleliterary style


Be efficientBe efficient

Medical records and outpatient chart entries should Medical records and outpatient chart entries should summarize presentation, evaluation, and care rendered in the summarize presentation, evaluation, and care rendered in the most efficient manner possible most efficient manner possible

The documentation of the most minute detail is often The documentation of the most minute detail is often unnecessary – an abridged version of the story often is most unnecessary – an abridged version of the story often is most appropriateappropriate

With time and experience students learn to master the art of With time and experience students learn to master the art of documenting a condensed version of the case documenting a condensed version of the case

The use of accepted acronyms and abbreviations also allows The use of accepted acronyms and abbreviations also allows

for more concise documentation for more concise documentation

Students and staff alike should avoid using arcane or little known acronyms or Students and staff alike should avoid using arcane or little known acronyms or abbreviationsabbreviations


Do not sacrifice details for space considerationsDo not sacrifice details for space considerations In focusing your documentation, be sure to include all In focusing your documentation, be sure to include all

relevant information – leaving out important details in an relevant information – leaving out important details in an effort to conserve space is a mistake that should be avoidedeffort to conserve space is a mistake that should be avoided

Early on in your career it is best to err on the side of Early on in your career it is best to err on the side of including too much information rather than overlooking vital including too much information rather than overlooking vital details in an effort to be concisedetails in an effort to be concise

With regard to history and physical this translates into the With regard to history and physical this translates into the recording of recording of pertinent pertinent positives and negatives – inclusion of positives and negatives – inclusion of everything the patient may have said and the entire everything the patient may have said and the entire physical examination is usually unnecessary physical examination is usually unnecessary

Reasoning behind medical treatment or surgical Reasoning behind medical treatment or surgical intervention should be recorded clearlyintervention should be recorded clearly

The medical record should allow any reasonably experienced member The medical record should allow any reasonably experienced member of the medical team to understand your thinking.of the medical team to understand your thinking.


Ensure that the information flows Ensure that the information flows logicallylogically

Regardless of the case complexity or medical Regardless of the case complexity or medical setting, documentation should follow a logical setting, documentation should follow a logical patternpattern

That is, the basic design of the patient That is, the basic design of the patient encounter should be reflected in the encounter should be reflected in the documentation – just as it is in case documentation – just as it is in case presentationpresentation

Historical facts should be recorded first, with Historical facts should be recorded first, with physical findings and diagnostic studies physical findings and diagnostic studies following nextfollowing next


Organize your thoughtsOrganize your thoughts

Documentation format typically reflects case Documentation format typically reflects case complexity complexity

Straightforward outpatient (and sometimes Straightforward outpatient (and sometimes inpatient) charting is organized using the inpatient) charting is organized using the standard S.O.A.P. format while cases of limited standard S.O.A.P. format while cases of limited complexity are typically organized by problemcomplexity are typically organized by problem

Significantly complex inpatient care is usually Significantly complex inpatient care is usually documented utilizing a “by system” approachdocumented utilizing a “by system” approach

S.O.A.P – StraightforwardS.O.A.P – Straightforward Subjective, Objective, Assessment, and Plan Subjective, Objective, Assessment, and Plan

This is by far the most commonly used documentation This is by far the most commonly used documentation format – as the vast majority of medical practice format – as the vast majority of medical practice involves the diagnosis and treatment of common involves the diagnosis and treatment of common disorders in an outpatient setting disorders in an outpatient setting

As with presentation, clearly delineating the subjective As with presentation, clearly delineating the subjective and objective portions is requiredand objective portions is required

Within the standard SOAP format, the assessment is Within the standard SOAP format, the assessment is often simply a notation of the diagnosis and possibly an often simply a notation of the diagnosis and possibly an indication of the exact etiologyindication of the exact etiology

The plan is typically a numbered listing of items The plan is typically a numbered listing of items comprised of treatment, patient education, and follow-comprised of treatment, patient education, and follow-upup

Often the assessment and plan are listed together as Often the assessment and plan are listed together as “A/P” and the entry that follows is a hybrid of the two“A/P” and the entry that follows is a hybrid of the two

S.O.A.P – StraightforwardS.O.A.P – Straightforward S)S) 33-year-old o/w healthy 33-year-old o/w healthy ♂♂ with c/o 4-day h/o ↑’ing bilateral eye irritation and with c/o 4-day h/o ↑’ing bilateral eye irritation and

discharge. discharge. Afebrile - o/w healthy – no chronic medical conditions. + contact with friendAfebrile - o/w healthy – no chronic medical conditions. + contact with friend

experiencing similar sx’sexperiencing similar sx’s

O)O) GEN: GEN: Alert, NADAlert, NAD HEENT: HEENT: Bilateral scleral injection and conjunctival hyperemiaBilateral scleral injection and conjunctival hyperemia

+ mucoid discharge/crusting at lid margin + mucoid discharge/crusting at lid margin PERRLA - PERRLA - EOMI EOMI no pain with movement of eye, NL visual fields - Vision no pain with movement of eye, NL visual fields - Vision 20/20 20/20

No evidence of peri-orbital edemaNo evidence of peri-orbital edema

A/P) Conjunctivitis – viral vs. bacterialA/P) Conjunctivitis – viral vs. bacterial

High probability of viral etiology, however, given increasing symptoms and High probability of viral etiology, however, given increasing symptoms and non-non- verification of bacterial source via culture, will treat empirically for likely verification of bacterial source via culture, will treat empirically for likely bacterial bacterial pathogens pathogens

Polymyxin B / SUL-TMP ophth soln Polymyxin B / SUL-TMP ophth soln 4 drops in each eye QID X 5 days as 4 drops in each eye QID X 5 days as directed directed RTC if sx’s worsen or persist greater than 5-7 days without improvement, eye RTC if sx’s worsen or persist greater than 5-7 days without improvement, eye

pain pain develops, or visual deficit occurs develops, or visual deficit occurs Dx, etiology, prognosis, disease course, med use/side fx, and hygiene Dx, etiology, prognosis, disease course, med use/side fx, and hygiene

discussed discussed with patient at length with patient at length

By PROBLEM – Limited By PROBLEM – Limited ComplexityComplexity

In an effort to maintain adequate organization in In an effort to maintain adequate organization in cases of limited to moderate complexity, a “by cases of limited to moderate complexity, a “by problem” approach is used to document the problem” approach is used to document the assessment and planassessment and plan

As discussed earlier, the historical and physical As discussed earlier, the historical and physical data format (subjective and objective) rarely data format (subjective and objective) rarely changes, regardless of complexitychanges, regardless of complexity

Quite simply, the by problem approach involves Quite simply, the by problem approach involves listing out the patient’s individual problems or listing out the patient’s individual problems or diagnoses and documenting an individual plan for diagnoses and documenting an individual plan for eacheach

““By problem” Assessment and By problem” Assessment and PlanPlan

A/P)A/P)

Atopic dermatitisAtopic dermatitis - - Acute treatment of symptomatic flare with topical hydrocortisone 2.5% Acute treatment of symptomatic flare with topical hydrocortisone 2.5%

ointment TID for 10 daysointment TID for 10 days - - Regular and liberal use of emollient each day – applied at a minimum in the Regular and liberal use of emollient each day – applied at a minimum in the

morning, after water exposure, and before bedmorning, after water exposure, and before bed

Mild Persistent AsthmaMild Persistent Asthma - - Continue BID use of inhaled corticosteroids as maintenance therapyContinue BID use of inhaled corticosteroids as maintenance therapy - - Albuterol MDI 1-2 puffs via spacer q4-6 hours prn cough, chest tightness, etc. Albuterol MDI 1-2 puffs via spacer q4-6 hours prn cough, chest tightness, etc. - - RTC/ER if required > q4h RTC/ER if required > q4h

Allergic RhinitisAllergic Rhinitis - - Continue nasal corticosteroid inhaler at one spray each nostril qHS for Continue nasal corticosteroid inhaler at one spray each nostril qHS for

maintenancemaintenance

-- Patient to follow-up in 6-8 weeks for ongoing care of above – RTC sooner Patient to follow-up in 6-8 weeks for ongoing care of above – RTC sooner for for any increased symptoms or concernany increased symptoms or concern

By SYSTEM approach – By SYSTEM approach – ComplexComplex

A by system documentation style is reserved for A by system documentation style is reserved for the most complex medical patientsthe most complex medical patients

Traditionally the subjective and objective data Traditionally the subjective and objective data remains at the initial portion of the chart entry, remains at the initial portion of the chart entry, with the assessment and plan alone broken down with the assessment and plan alone broken down into systems. into systems.

In extremely complex and heavily-detailed cases, In extremely complex and heavily-detailed cases, even the subjective and objective portions may even the subjective and objective portions may be broken down into systems! be broken down into systems!

““By problem”By problem” FEN:FEN: Pt has 18 gauge IV site in left antecubital Pt has 18 gauge IV site in left antecubital

fossae. Full maintenance IVF while NPO awaiting fossae. Full maintenance IVF while NPO awaiting angiocath. Strict monitoring of I/O’s. Chem 7 angiocath. Strict monitoring of I/O’s. Chem 7 qAM. Adequate urine output over past 24 hours.qAM. Adequate urine output over past 24 hours.

CV:CV: Patient with significant history of Patient with significant history of

cardiovascular disease. HTN controlled with daily cardiovascular disease. HTN controlled with daily ACE-inhibitor therapy, history of stable angina ACE-inhibitor therapy, history of stable angina with symptomatic relief provided with with symptomatic relief provided with nitroglycerin sublingual tabs. On exam, patient nitroglycerin sublingual tabs. On exam, patient has RRR with no evidence of M/R/G. Distal pulses has RRR with no evidence of M/R/G. Distal pulses are strong. HR is 64 and BP is 140/88. Plan for are strong. HR is 64 and BP is 140/88. Plan for continued outpatient medication therapy while continued outpatient medication therapy while admitted with strict monitoring of BP (as he admitted with strict monitoring of BP (as he remains high-normal despite medication).remains high-normal despite medication).

Classic systems used in documentation Classic systems used in documentation include. . .include. . .

FEN:FEN: Fluid, electrolytes, nutrition Fluid, electrolytes, nutrition

HEENT:HEENT: Head, eyes, ears, nose, throat Head, eyes, ears, nose, throat

CV:CV: Cardiovascular Cardiovascular

PULM:PULM: Pulmonary Pulmonary

GI:GI: Gastroenterological Gastroenterological

GU:GU: Genitourinary Genitourinary

NEURO:NEURO: Neurological Neurological

DERM:DERM: Dermatological Dermatological

MS:MS: Musculoskeletal Musculoskeletal

By SYSTEM approach – By SYSTEM approach – ComplexComplex

A by system approach is commonly reserved for A by system approach is commonly reserved for intensive care unit documentationintensive care unit documentation

However, exceptionally ill ward patients may However, exceptionally ill ward patients may require a by system approach as wellrequire a by system approach as well

As ward patient complexity increases and a by As ward patient complexity increases and a by system approach becomes increasingly system approach becomes increasingly warranted, you may also want to consider warranted, you may also want to consider transferring the patient to an intensive care unit transferring the patient to an intensive care unit setting!!setting!!

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Final thoughts. . .Final thoughts. . .

Adherence to the principles presented here will Adherence to the principles presented here will guide you toward skillful documentationguide you toward skillful documentation

Students should bear in mind that the goal of Students should bear in mind that the goal of documenting patient care is simply to create a documenting patient care is simply to create a clear and concise record of the patient’s clear and concise record of the patient’s presentation, evaluation, and treatmentpresentation, evaluation, and treatment

Staying focused on this objective will allow you to Staying focused on this objective will allow you to develop proficiency in documentation – thus develop proficiency in documentation – thus adding another valuable tool to your medical adding another valuable tool to your medical arsenalarsenal

Questions??Questions??

Documentation The other cornerstone of Western medicine.

Documents

documentation peer review

appropriate documentation

patient slide

later review

consent legal documentation

patient presentation

care medicine

orders legal documentation