1

The Essentials of Medical Charting

9/17/09

Chief Complaint:

Present Illness:

Past History:

Review of System:

Physical Exam:

Diagnosis:

Management Plan:

HemorrhoidsHemorrhoidsHemorrhoidsHemorrhoids (+)Hemorrhoids (+)HemorrhoidsHemorrhoidectomy!

2

The Admission Record

Parts of the Admission Record

HISTORY

Basic Data Chief Complaint(s) Present Illness Past History Current Medications Family History Personal & Social History Travels Immunization Review of Systems

OBJECTIVE FINDINGS

Physical Examination Laboratory Findings Investigation

(Diagnostic Studies) Radiology Specific Findings

CONCLUSIONS

Tentative Diagnosis(es) Management Plan

3

Chief Complaint

State the problem and its duration

Nausea and poor appetite for 3 days

Or time of onsetCoughed up bloody sputum the night before admission

Or bothChest pain for 20 minutes at 5 hours before admission

Chief Complaint

Hematemesis and melena for 2 days Vomited blood and passed dark stoolsDysarthria and right hemiparesis since this morning Slurred speech and right arm and leg weakness

If admitted for special treatment or procedure, state the treatment/procedure and the problemAdmitted for percutaneous transluminal angioplasty of

occluded AV shunt

To receive post-thyroidectomy radioiodine ablation therapy for papillary thyroid cancer

4

Present Illness

Tells the story of events that led to the patients present hospitalization

Chronological, descriptive, organized

Emphasize information that supports your tentative diagnosis

Exclude irrelevant, non-contributory information

Content of the Present Illness

1. Background information 2. State of health prior to present illness

3. Description of main symptoms 4. Pertinent negatives 5. Course of present illness 6. Findings and interventions at other healthcare

facilities prior to this admission

5

Content of the Present Illness

Begin with the patients background informationAge, race (ethnicity), sexPast history, procedures, and operations that have a relationship or impact on the present illness or may influence management

CC: Cold sweating and tremor this morning

PI: The patient is a 69-year-old Minnan Taiwanese man with type 2 DM for 20 years, DM nephropathy in stage 5 chronic kidney disease, DM gastropathy, and alcoholic liver disease who has been treated with insulin and has recently begun hemodialysis at our hospital.

Content of the Present Illness

State of health or degree of disease control prior to the present illness

The patient has been bed-ridden and dependent on home O2 use since he was discharged from the respiratory care center 2 months ago.

The patients blood glucose at home fluctuates from 70 to over 300. His blood pressure has been usually above 145/95 mmHg.

6

Content of Present Illness

Description of main symptoms1. Onset/Trigger 2. Quality 3. Quantity or severity 4. Location and radiation 5. Frequency 6. Duration 7. Alleviating factors 8. Exacerbating factors 9. Associated symptoms 10.Time course

Present Illness: Describing Symptom

His abdominal pain developed shortly after a binge of alcohol drinking last evening (). The pain was dull and gnawing (). It began in the mid-upper abdomen but spread to the back in a band-like fashion (). It was felt intermittently about once every hour throughout the night () and would gradually subside within about 20 minutes (). Initially he rated the pain as 5 on a scale of 1-10 (), but it soon worsened to a score of 8 to 9 and later became persistent (). Antacid relieved the pain slightly (), while eating and drinking made it worse (). During the night he also became increasingly short of breath ().

7

Content of Present Illness

Pertinent negativesHelp to exclude certain diagnoses

The patient did not have dyspnea and cold sweating. His chest pain was not relieved with nitroglycerin and rest. ECG at the clinic did not show any abnormality.(therefore cardiac ischemia is less likely)

For several days before his loss of consciousness, the patient had not been taking his DM medication.(therefore hypoglycemia is unlikely)

Content of Present Illness

Diagnostic studies and treatments given elsewhere before this admission

At Lukang Hospital ER, chest X-ray showed patchy

pneumonic infiltration in left upper lung. He had a fever

of 39 C. Oxygen saturation was 93% while breathing

room air. Sputum and blood cultures were collected. He

was given a dose of ampicillin/sulbactam 1.5 g and

acetaminophen prior to transfer to our ER.

8

Past History

Past medical illnessesAll inactive, already resolved medical problemsOngoing problemsInclude major past interventions and treatmentsHospitalizations

2/2001: Hypertension, regular medical treatment at cardiology clinic since 4/2002

12/2005: Three-vessel CAD, successful PCI for LAD

1/2007: Left MCA infarction with right hemiparesis, regular physical therapy since then

Past History

Past surgeries / procedures and outcomes1998: Laparoscopic cholecystectomy for cholecystitis

2002: Left subtotal thyroidectomy for Gravess disease, resulted in post-surgical hypothyroidism

Gynecologic / obstetric history Prenatal and birth history (12 ) Current medications

Regular medications prescribed in the clinic

9

Other Health-related Information

Family historyInheritable, transmissible, prevalent diseases, cancersAt least 3 generations, draw pedigree

Personal historySubstance use: tobacco, alcohol, betel nut, IV drugsLifestyle: exercise, diet, sexual activity, habitsOccupation (prior to retirement or unemployment)Social/family: marital status, dependents, finance

Travels and other exposures Immunizations

Hepatitis A/B, influenza, pneumococcal

Review of Systems General: fatigue, weakness, fever,

chills, weight change Skin: rash, lesions, pigmentation Head: headache, trauma, dizziness Eyes: vision, visual field, diplopia,

spots, discharge Ears: hearing, tinnitus, discharge Nose: congestion, obstruction,

epistaxis, smell Throat/mouth: bleeding, ulceration Respiratory: dyspnea, cough,

sputum, hemoptysis, wheezing Cardiovascular: chest

pain/tightness, palpitation, orthopnea, exertional dyspnea, nocturnal dyspnea

Gastrointestinal: dysphagia, heartburn, nausea/vomiting, hematemesis, abdominal pain, diarrhea, constipation, melena

Genitourinary: frequency, urgency, hesitancy, incontinence, dysuria, hematuria, menstrual irregularity, erectile dysfunction

Endocrine: polyuria, polydipsia, polyphagia, temperature intolerance

Musculoskeletal: arthralgia, arthritis, trauma, joint swelling, limitation of motion, back pain

Neuropsychiatric: seizures, muscle weakness, coordination, memory mood, emotional disturbance

10

Review of Systems

negative (-) positive (+) note

Foley incontinence

Physical Examination Vital signs: TPR, BP, orthostatic

changes, weight, height, BMI General: appearance, signs of

distress, development, habitus Skin: rash, turgor, pigmentation Head: size, shape, trauma Eyes: conjunctiva, pupil

size/reaction, ocular movements, acuity, visual fields, proptosis

Ears: hearing, tenderness, discharge

Nose: lesions, sinus tenderness Throat/mouth: lips, tongue, pharynx Neck: range of motion, jugular vein,

lymph nodes, thyroid, carotid bruit Heart: rate, rhythm, apical pulse,

murmurs, heart sounds

Chest: symmetry, tenderness, fremitus, expansion, percussion, breath sounds

Breast: palpation, nipple discharge Abdomen: shape, tenderness,

percussion, bowel sounds, hepatomegaly, splenomegaly

Extremities/musculoskeletal: deformities, joint swellings, edema, range of motion, cyanosis

Rectal: hemorrhoids, sphincter tone, masses, prostate, stool

Vascular: peripheral pulses, bruits Neurologic: mental status, cranial

nerves, strength, sensory, cerebellar signs, coordination, reflexes

11

Physical Examination

General Appearance Signs of distress

In mild, moderate, or severe distress; comfortable, no sign of distress

mood: Anxious, restless, cheerful, indifferent, depressed, tearful

body habitus: Obese, thin, tall, short

nutrition status: well-nourished, malnourished

Laboratory Test Results

Specify condition pertinent to sample collection

Hb (before or after transfusion?), ABG (FIO2?), CRP (before or after antibiotic?), cortisol level (8 or 4 PM?)

CalculationsCa2+ level adjusted for albumin, Na+ corrected for hyperglycemia, corrected reticulocyte count, etc.

Include old lab results for comparison and for demonstrating serial changes when necessary

Rise in cardiac enzymes, serial changes in absolute neutrophil count, etc.

12

Investigation Imaging and other diagnostic studies

X-ray findings (draw or paste PACS image)ECG interpretationSonographic findings, CT, MRI, endoscopy, pathology report, etc.

Specific Findings Important findings from physical exam, laboratory

tests, and investigation that need special attention or support your tentative diagnoses

Assessment: Terminology

Diagnosis: the art or act of identifying a diseasefrom its signs and symptoms

Merriam-Webster Dictionary

=

Problem: any abnormality that needs attention

Can be a symptom, sign, lab finding, or imaging findingCan be medical, social, or psychiatricCan also be a diagnosis

13

Diagnosis

Risk factors, predisposing conditions

Underlying disease, disorder, or syndrome

Chronic complications Acute complications

Observed problems:Symptoms, signs, lab findings, study findings

Precipitating factorsTriggering events

Other risk factors,predisposing conditions

DiagnosisRisk factors, predisposing conditions

Obesity, family history of DM

Underlying disease, disorder, or syndrome:Type 2 DM

Chronic complicationsDM nephropathy

Acute complications:Hypoglycemia

Observed problems:Impaired consciousness, blood glucose 24 mg/dl,

proteinuria, azotemia

Precipitating factors:Poor intakeSulfonylurea usePoor renal function

Other risk factors,predisposing conditions:

Hypertension

14

Assessment: Terminology

Tentative diagnosis: diagnosis which is uncertain or unconfirmed

Differential diagnosis: alternative diagnosis for the observed problem

Favor / suspect ___: diagnosis you believe is likely Consistent / compatible with ___: diagnosis with

strong evidence supporting it Possible probable confirmed, definite Rule out ___: diagnosis that needs to be excluded

Not necessary the most likely diagnosis

Assessment: Listing Problems

Main problem that led to hospitalization on top Then list other problems in order of urgency List the specific diagnosis if it is certain

Under each diagnosis list its complications1. Active pulmonary tuberculosis, complicated with:

A. Respiratory failure, requiring ventilatorB. Moderate left sided pleural effusion

2. Type 2 DMA. In hyperosmolar hyperglycemic state

1) Acute oliguric renal failure due to dehydration2) Hypokalemia

B. Proliferative DM retinopathy

15

Assessment: Listing Problems

If the diagnosis is uncertain, list the problem, then discuss putative underlying causes and differential diagnoses1. Shortness of breath

A. Most likely asthma exacerbation because he has wheezing

B. Acute coronary syndrome also possible because he has multiple CVD risk factor and has ECG changes

C. Anemia is unlikely the cause, but may be contributory

2. Normocytic anemiaA. Probably secondary to chronic renal failure

B. Occult GI bleeding also possible because of aspirin use and past history of duodenal ulcers

Management Plan

Initial and subsequent treatments, procedures, interventions, labs and studies, consultations

May group plans under each problem1. For left foot cellulitis

A. IV oxacillin 1 g q6hB. Foot x-ray to look for gas formation and foreign bodyC. Consult surgeon for foot wound debridement

2. For heart failureA. Oral furosemide 40 mg bid, adjust dose according to daily I/OB. Echocardiogram to evaluate heart functionC. Limit fluid intake to 1 L/day, salt to 3 g/day

16

Management Plan

Be specific about each planSpecific medication, dosage, route and durationContinue IV hydrocortisone 100 mg q8h for 2 days after surgery, then taper to oral cortisone at 25 mg daily

Co-Diovan, Avandamet

Specify indication for lab tests and diagnostic studiesAbdominal ultrasound to check for ascitesAvoid vague, general statementsSearch for underlying cause, infection survey, supportive care, expectant management, empiric antibiotic treatment, adequate hydration, correct electrolyte imbalance, sugar control, keep vital signs

Progress Note

17

Progress Note

A record of daily changes in condition, treatment response, new diagnostic findings, revision of diagnoses, and modification of management plan

Modified POMR Problem-oriented approachCombined with SOAP format

Must write date and time / / 8/22/08 16:30 or August 22, 2008 16:30

Sign full name () after each note

Progress Note

SubjectivePatients complaints, changes in symptomsPatients appearance, level of consciousnessSignificant events in the past 24 hours

ObjectiveI/O, weight, tube drainageSignificant physical findingsNew lab and diagnostic study results

18

Progress Note

List each problem, then write assessment and plan under each problem

Assessment1. Status of problem: improving? worse? stabilized?2. Diagnosis

Any definite diagnosis for the problem? Any revision or update for the diagnosis? Rationale for the diagnosis? Supporting evidence? Precipitating factor or triggering event for the problem? Risk factors or predisposing condition for the disease?

3. Response to treatment

Progress Note

Management planCorresponds to the problemAny changes in medication, dosageDuration or time since treatmentDay #3 of ceftriaxoneDay #4 of chemotherapy withOn mechanical ventilator support day #10Further diagnostic studies, laboratory testsTherapeutic procedures, consultations, discharge planning, etc.

19

Progress Note: POMR + SOAPDate and time

Progress Note

Vital signs, pain VAS

Subjective:

Objective:

Problem #1 _____

Assessment:

Plan:

Problem #2 _____Assessment:Plan:

Problem #5Assessment:Plan:

Inactive problems:#3 _____#4 _____#6 _____

Sign name_____

Progress Note6/17/09 14:30

Progress NoteBT 36.4 C, P 95, RR 14, BP 120/70 mmHg, pain VAS 0/10

S: Greenish stools twice today. No abdominal pain.Less thirst and nausea. No shortness of breath. More alert and talkative today.

O: CVP 2 cmH2O, I/O 3500/2700, BW 46 kgNG decompression: no more coffee groundPE: Pale face and conjunctivae

Regular heart beat, clear breath sounds bilaterallyAbdomen: non-tender, bowel sounds hyperactive Skin dry with poor turgor, no peripheral edema

Labs: Hct 28% yesterday, 30% todayBlood glucose 152, 98, 176 this morningNa+ 141 meq/L, K+ 3.2 meq/L

20

Progress NoteProblems

1. Upper gastrointestinal bleedingA: A bleeding duodenal ulcer (A1) was found via upper endoscopy

this morning. It may be related to patients long-term use of NSAIDs. Bleeding was easily controlled with hemostasis and now appears resolved. Patient is hemodynamically stabilized and without sign of rebleeding.

P: Begin diet as toleratedStop IV omeprazoleStart oral esomeprazole 40 mg once dailyRemove NG tube

Progress Note2. DM complicated with diabetic ketoacidosis

A: Patients young age, ketoacidosis, and light body weight suggest type 1 rather than type 2 DM. Glycemia is now adequately controlled with insulin infusion at low rate. He has no more sign of acidosis, but is still volume and electrolyte depleted.

P: Keep insulin infusion at 0.5 U/hrIncrease KCl to 80 meq/dContinue IV normal saline at 3500 ml/dStart IV D5W at 100 ml/hr if blood glucose is < 150 mg/dL

21

Progress NoteInactive problems:3. Gouty arthritis4. Asthma5. DM nephropathy6. Non-proliferative retinopathy

________

Discharge Summary

22

Discharge Summary

Admitting diagnosesTentative diagnoses as in the admission record

Discharge diagnosesList the main diagnosis first

The diagnosis which directly led to this admission

Then list the secondary diagnoses in order of importance or severity

Problems that developed during hospitalization Pre-existing or underlying problems that affected management

or hospital stay

Discharge Summary

Discharge diagnoses (cont.)Be specific

UGI bleeding vs. duodenal ulcer bleedingUrinary tract infection vs. Acute left pyelonephritis and

bacteremia due to E. coli infection

Include major interventions done for the main problemsDecompensated stage 5 chronic kidney disease s/p initiation of

hemodialysisSick sinus syndrome s/p permanent pacemaker implantation

Include complications during hospitalizationRight pneumothorax due to central venous catheter puncture

23

Discharge Summary

History and physical findings on admissionSummarize present illness and physical examination findings as stated in the admission note

Hospital courseMay use problem-oriented approachHow each problem was evaluated; results of major diagnostic procedures and laboratory testsTreatments and interventions given for each problemPatients response to treatment and outcomeNew problems that developed during hospitalization and their management

Sample Hospital CourseThe patient was initially kept NPO and given IV hydration

with normal saline. He was transfused with 2 units of packed RBC, which raised his Hb to 9 g/dl. Upper GI endoscopy on 8/28 revealed a bleeding A1 gastric ulcer and hemostasis was achieved with heat probe. Initially IV omeprazole was given, but was then switched to oral esomeprazole on 8/29 when he began feeding. By 8/30 his stool had turned greenish and abdominal pain had resolved.

Hyperglycemia was initially managed with IV insulin infusion. Afterwards his blood sugar remained < 200 mg/dl. IV insulin was switched to bid injections of HM 70/30 as he began to eat. Dose was adjusted until BS was < 250 mg/dl.

Throughout his stay, the patients blood pressure remained below 120/65, therefore his amlodipine has been withheld.

24

Discharge Summary

Complications during hospitalizationNosocomial infection, transfusion reaction, adverse drug reactions, surgical or procedural complications, etc. that affected management or prolonged hospital stay

Significant diagnostic findings (labs, imaging, etc.)Record only clinically significant findingsIf no report yet at time of discharge, write result pending

Discharge Summary

Operations, anesthesia, invasive procedures and their outcomes and findings

Condition at discharge and dispositionImproved, stable, or unstableAny unresolved problems (go home with Foley, NG tube, bed sore wound care, etc.)Clinic follow up, home care, referral, etc.

Discharge medication and instructions to patientsSpecific medication (generic name), dosage (not 1#, 2#), amount dispensed

25

Suggestions for Improvement

The patient presented with drowsy consciousness The patient presented with drowsiness

According to the statement of the patients son... According to the patients sonThe patients son stated that

Patient came to the ER for helpUnder the impression of COPD and pneumonia he is admitted for further evaluation and management.

indications Because of marked respiratory distress and evidence of septic shock the patient is therefore admitted.

26

Get, gotThe patients wound gets better everyday

The patients wound improves everyday

His constipation got relieved after the enema His constipation was relieved after the enema

Besides,Besides, patient also had fever and cough

In addition, patient also had fever and cough Besides

Besides sore throat, patient also had fever

She is a victim of colon cancerShe is a colon cancer patient

Unfortunately, he had a stroke last yearHe took an NSAID, but in vain

He took NSAID, but symptoms did not improve;His symptoms were not relieved with NSAID

Seizure attacked himHe had a seizure episodeHeart attack, asthma attack, gout attack ()

Patient escaped from treatment after 2 weeks.Patient discontinued treatment

27

Chillness? : chills , chilliness Chocking? : choking LMD?

primary care physician, doctor at local clinic Chest man, CV man, GI man, infection man?

( Superman, Spiderman, Batman )pulmonologist, cardiologist, gastroenterologist()

On endo, on NG tube, on Foley, on CVP?On : endotracheal intubation, NG tube insertion, Foley catheterization, central venous catheter cannulation

Underline (?): underlying illness underlying problem

MBD?: discharge patient , discharge in a.m., discharge home, discharge to nursing center

AAD?: discharge against medical advice, discharge AMA

28

Was told: He visited ENT, and URI was told: He was told / was informed by ENT doctor to have URI

Was complained: No thirst nor polyuria was complained: Patient did not complain of thirst or polyuria

Happened to: Chest pain happened to him during exercise.: Chest pain developed during exercise. He had chest pain during exercise.

Conscious (); consciousness ():conscious unclear, conscious change, conscious disturbance, conscious level, drowsy conscious, conscious loss:The patient remained conscious (or unconscious)The patient arrived in an unconscious stateThe patient lost consciousnessThe patient presented with altered consciousnessHis consciousness was impaired

29

Active vs. passive tense vs. admit, admitted

: Patient admitted to the hospital yesterday.

The patient was admitted to the hospital yesterday.The doctor admitted the patient yesterday.

Intransitive verbs complain

: The patient complained nausea and vomiting.

The patient complained of nausea and vomiting.The patient complained to the doctor about nausea.

man woman boy girl The patient is a 56-year-old woman with

male female : male infant, female patient, male nurse: The patient is a 20-year-old male with, This is an adult female who

caseThis is a case of Parkinsons disease

30

Since vs. From

Since Acute onset of left leg weakness since 2 days ago

Acute onset of left leg weakness 2 days ago

Left leg weakness since 2 days ago

From Usually follow by a to

Left leg weakness from 2 days before admission

Left leg weakness from 9 a.m. to 11 a.m. yesterday

Left leg weakness since 2 days before admission