Jarrod Shapiro, DPM reviews the fundamental concepts of medical documentation. Specific documents discussed include: the consultation note / history and physical, operative report, admitting orders, operative note, follow-up SOAP note, and discharge summary. This is done through a case presentation format with downloadable templates provided for the viewer's education. Topics also discussed include methods to prevent medical errors through appropriate charting and basic chart rules.
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21st Century Medical Documentation-1,2,3
Author: Jarrod Shapiro, D.P.M.
Western University of Health Sciences
College of Podiatric Medicine in Pamona, California
My name is Jarrod Shapiro, I'm an assistant professor at the Western University of Health Sciences, College of Podiatric Medicine in Pamona, California, and I've been asked to discuss medical documentation.
During our discussion we'll review various topics surrounding medical documentation with an emphasis on a practical approach to medical charting. The two primary goals of our discussion today are to instruct on the proper methods of modern medical documentation and more importantly to decrease the risk of medical errors through appropriate charting and documentation. To this end, we'll review the importance of modern medical documentation, appropriate methods of documentation under various circumstances, and review tools to reduce errors.
Due to the nature of this topic some of the slides are quite dense, so at any point in the lecture the viewer should feel free to pause the slide to review the information or read through the supplied charting samples. Additionally, we've supplied downloadable templates for each of the chart types. Click on the chart icon to access and download these templates.
We're going to quickly cover each of the following document types using a clinical case study. As we go through the case, we'll examine the following chart notes: A consultation note, very similar to a history and physical, an operative report, admitting orders, an operative note, a followup SOAP note, and a discharge summary. The case study will focus around a diabetic patient admitted to the hospital through the emergency room from an infection, specifically an abscess with osteomyelitis that you as the attending physician have been consulted to see and will follow up from admission through surgery to discharge.
You'll see the difference between the various chart notes and the SOAP note format. Appropriate documentation requires the basic format of each to be memorized. Each of these documents has a standard form so that all members of your medical community can understand and rapidly acquire the information you have written. Again, as we go through each note, we'll have a link to a generic or template document that you can use in future situations.
So what is medical documentation and why do we have it? The modern patient-centered medical record system was started about 1910 and advocated by Abraham Flexner, who was also the author of an influential document, the Flexner Report that changed the medical education system in the United States to the form in which it exists today. The medical document is primarily a means of communication, both between medical practitioners and oneself. The chart allows others to understand your reasoning process as well as planned treatment and concerns. It's also a method to prevent memory errors. The chart is a simple method to remind ourselves what's happening with our patient. The medical chart is also a method that when applied appropriately will prevent errors. On the flipside, the medical chart can also be a cause of errors. We'll discuss in a few minutes how this may occur and how to prevent these errors.
A thorough medical document also affords medicolegal protection. Those in the medical profession are familiar with the phrase "if it's not in the chart, it didn't happen." This is a doctor's opportunity to place all events in the permanent record, thus protecting him or her during litigation. On the other hand, a poorly written document is often the reason a doctor will lose a lawsuit. It's beyond the purview of this lecture to discuss coding and billing, but it's important to note that the medical chart determines the level of reimbursement the physician receives for her services and provides protection in the event of an insurance audit. Inappropriate documentation will result in lost wages from the doctor. For example, the failure to document a review of systems will decrease the complexity of the note and, therefore, support a lower level of payment for the doctor.
So what isn't medical documentation? Medical documentation is not your soapbox, it's not a place for you to complain about your patient, the family or other physicians or staff. The chart note is the professional legal document in which you as the expert document the history, findings, assessment, and plans for treatment. It's not a form to vent frustrations with individuals or the system. It is a dispassionate document to help your patient. The chart is not a place to lie. It's often difficult to admit error and complications, but the medical document requires honest input, not obfuscation and omission. This is also not an opportunity to pre-label a patient. Derogatory terms that may sway the opinion of other healthcare workers reading your note have no place in the chart.
Every patient deserves equal care, no matter their situation in life, and the chart if it contains labeling information may cause unbalanced care. For example, a patient unable to speak English or somewhat uneducated is not stupid and should not be labeled this way. Rather the document may legitimately state the patient is an exclusive Spanish speaker or has completed an elementary school education. This is more objectively stated information and may be important during the counseling or prescribing complicated medication regimens. Using objective descriptions communicates important issues without labeling the patient.
The chart note is also not your opportunity to show bias against someone else. Just as you should never denigrate another healthcare provider in front of a patient or really at all, the chart note should not demonstrate your bias. There's nothing wrong with stating a physician's name in the chart. For example, the chart can state tendo Achilles lengthening by doctor so-and-so one week prior. The chart should not say doctor so-and-so screwed up the tendo Achilles lengthening. Objectivity is key.
Another important characteristic of the medical chart is its ability to decrease and in some cases increase medical errors. Medical errors happen daily. All physicians, regardless of experience, will make a medical error. An error might be prescribing the wrong medication or the wrong dose, or even the wrong route of administration. An error might also occur as a result of someone else mistaking what you wrote, essentially a communication error.
If you think medical errors are rare, then think again. In 1999 a landmark paper was published by the Institute of Medicine called "To Err is Human", which brought to light the hidden tragedy behind the medical profession. Studies at the time found that up to 98,000 American deaths per year were due to preventable medical errors. Recent work has shown this number may be an underestimation since the original study did not include preventable deaths outside of hospitals. In fact, it may be as high as 150,000 people per year. This is the equivalent of a jumbo jetliner full of patients falling from the sky and killing all aboard every day, and yet this problem goes almost unnoticed by the general public. Medical errors are now the eight leading cause of death in the United States beating out breast cancer, traffic accidents or AIDS. Why is this? The answer is simple, familiarity bias. When an airplane falls from the sky, many people are killed at once, but we in the medical community kill our patients one at a time. It's our responsibility as physicians, nurses, and staff to take care of other people to do everything we can to eliminate this problem.
It's not enough to just write a note in the chart. It's as important or may be more important to write chart notes, prescriptions, and orders appropriately in a way that reduces confusion and errors. So, we're now going to discuss the issues associated with clear notes that reduce errors and complications.
As I mentioned, it's not enough to write a note or an order. It has to be done in a way that others understand. Remember, nurses aren't mind readers. They need clear information to follow your orders. We've all heard the joke that doctors have poor handwriting. Well, it's not such a joke when you look at the statistics. According to the Agency for Healthcare Research and Quality, an estimated 6% of hospital medication errors are due to poor handwriting. Think about that for a moment. That means out of every 100 patients you see, 6 of them will have a medication error due to preventively poor handwriting. How would you feel being one of those 6?
Take a look at this real prescription. Do you know what this medication error is? The medication dispensed to the patient was the anxiolytic BuSpar, but the doctor actually prescribed Prozac. Clearly, this error is due simply to poor penmanship. BuSpar and Prozac may be used for similar disorders, but they're in completely different classes with different mechanisms of action and different potential hazards. Would you trust your pharmacist to decipher the script?
How about this one? If you were the nurse about to administer this insulin order, how much insulin would you give your patient? 60 units? The 'u' looks like a 0 here and the real patient actually received 60 units instead of 6 units, a tenfold amount more than they were supposed to receive. What can happen if you overdose a patient on insulin? Hypoglycemic coma and death, very possibly an extra 5 seconds for cautious handwriting could have prevented this significant error.
Now that we know the importance of cautious charting, let's review some basic charting rules to further prevent documentation errors. A common error I've seen with residents is to forget to date, time or sign their orders on chart notes. An appropriate signature is legible with the level of training for students, residents, and fellows, and a number appended to the signature. For example, I might sign my note as J. Shapiro, M.S.4, pager 1023 if I were a fourth year student. Again, your signature must be clear. Few things frustrate hospital staff worse than having to decode doctor's handwriting. Would you want to be the floor nurse trying to decode a signature at 2 a.m. when your patient's having a complication?
Another important point for the resident is to leave room at the bottom of a note for your attending. They will need to add a short note at the bottom that they reviewed and concurred with the resident's findings and plan, or they may disagree and add changes to the chart. If you're a resident, think about how bad you'll look to the attending while you're running around trying to find another progress note sheet while they are impatiently waiting for you so they can move on to the next patient.
Write in black ink. No pencils, pretty colors or artwork. Remember, this is an official document for the patient's chart. It's okay to make an error, simply cross it out with a single line through the middle of the word or phrase. Don't scribble it out, don't white it out, don't remove the page with the error. Write the word error above the word with your first initial and last name and date.
All notes and dictations should be timely. Dictate or write notes as close to the event as possible. Don't wait 48 hours to dictate an operative report. Your memory of the encounter will become less complete and accurate as time goes by. Also, start your notes with the appropriate header. A podiatry note may be headed as Podiatry or you may have a specific designation such as Limb Salvage Service. For residents, some attendings will want their names with the header. Be sure to check.
Some further points include the time of charting and what to do with vacant spaces. Chart notes and reports should always be completed immediately and after the event. Pre-charting or completing a document before the actual occurrence should be avoided for the obvious reason that accuracy will suffer. It's impossible to predict all events during any patient encounter and this type of documenting breeds dishonesty and inaccuracy. The same is true for blank spaces in a patient record.
For handwritten charts, lines and extra spaces should be obliterated by a single line or multiple lines if a large space remains. This eliminates the possibility of altering the chart at a later date, which has the added benefit of being a stronger medicolegal document.
As we saw earlier with our erroneous insulin order, caution with abbreviations is a must. Here is a list of specific abbreviations that are commonly used but may lead to medical errors and are now no longer permitted by many hospitals. To point out a couple of specific avoidable abbreviations, the letter 'u' should be avoided because of the ease in which to confuse it with the letter 'o' or number '0'. Micrograms should not be designated by the Greek '�g' because it can easily be confused with 'mg' for milligram. A common abbreviation I've used is 'DC', which although commonly used can be mistaken for either 'discharge' or 'discontinue'. Avoiding these abbreviations will greatly reduce the possibility of miscommunication. So when in doubt, write it out.
Just as abbreviations can lead to errors, so too can numbers. To prevent detrimental patient errors never leave a naked decimal. In the first example, 0.6 mg of colchicine can be easily mistaken for 6 mg, placing the leading 0 before the decimal will obviate this mistake. Similarly, don't use a terminal zero; 1.0 g of cefazolin may look at a rapid glance like 10 g, avoid this error by eliminating the terminal 0. In this final example, leaving a space between the drug name and its dose will avoid an overdose of Inderal.
I wanted to make a few comments about dictating. Dictating well is an art. The hard part about dictating is verbalizing concisely without adding any extraneous information. Students and residents often have trouble adapting to dictation because they're not used to speaking to a recorder on the phone. For those of you just learning this skill, be patient with yourself and understand that it takes experience to dictate well. Listen to others dictate and read your dictations when you receive them for signatures. This will help speed up the learning process.
Students often don't get the chance to dictate until they start residency. To acquire this skill early, I would recommend dictating into a handheld recorder or your computer, transcribing what you've dictated and then comparing that to the actual dictation if you can get a hold of it. When dictating it's important to include your name, the patient's name, the patient's medical record number, the date of their birth, the date of dictation, and the date of the encounter. Before you forget, ask to carbon copy or 'cc' the letter to the referring physician. From a practice management standpoint, this is a must. During your dictation speak rapidly and clearly. Try not to mumble and spell out words that are easy to mistake or are specialty specific. Your transcriptionist will know the word 'hallux' or 'edema', but might not know how to spell 'lipodermatosclerosis'.
Now that we're safely documenting to avoid potentially deadly errors, let's discuss the specifics of charting. The SOAP note is the basic structural template of clinical documentation. SOAP stands for Subjective, Objective, Assessment, and Plan. All clinical notes will have this basic structure. This is true for the history and physical, consultation, preop and postop notes, and followup notes. You'll see as we go that the various sections of more complex notes actually fit into this simple format. Many older physicians will document all their notes this way, but contemporary documentation expands this.
The power behind this system is that it follows exactly the same format as the interactions with your patients. You first gather the patient's story and their prior history, the subjective section, and then do a physical examination and gather labs and imaging data, the objective. From these pieces of information you come to a diagnosis or at least a differential diagnosis, which is the assessment, and then provide treatment, the plan. It's intuitive, user-friendly, clear, and allows the physician to effectively communicate with other caregivers.
Let's quickly talk about each section. The 'subjective' section is just that - subjective. This is the part where you as the doctor listen to your patient's complaint. This is a narration of the patient's problem and is often appropriate to put his or her statements into quotations. For example, the complaint might be "my right heel hurts." A useful mnemonic to elicit a complete history is NLDOCAT - short for Nature, Location, Duration, Onset, Condition, Aggravating and Alleviating factors, and Treatment. There's no more important section than the patient's history. Capturing all this information will generally provide all the data necessary to diagnose the complaint most of the time. This section would also include other physicians seen, other presumed diagnoses, prior therapies, and the response to those therapies up to the present time.
Let's take a slight diversion and look at the review of systems. We'll see where the review of systems lands in the broader H&P and consult notes, but it's also an important part of the subjective section of a SOAP note. The review of systems is a screening tool that allows the caregiver to elicit problems that may be avoided or forgotten by the patient.
Listed here is a comprehensive review of systems covering all major organ systems. This level of completeness will be important in a preoperative evaluation where a more focused review of systems would be appropriate in most other cases. For example, if I were seeing a patient for followup treatment of plantar fasciitis for whom I prescribed an NSAID anti-inflammatory, my review of systems might look something like this, since NSAIDs cause GI, skin, allergic, and cardiac complications.
Similarly, during a preoperative history and physical, I might focus my review of systems on prior anesthetic complications, GI issues, cardiopulmonary disease risk factors, and history among others. A suggestion for those in practice will be to add a review of systems to the patient data intake form. It's appropriate to state in your note the review of systems was reviewed and is in the chart and still code for the corresponding complexity. This saves both time and money on the length of dictations.
Click on the chart icon to access and download these templates.
The objective section of the chart note should be a description of the vitals, physical exam findings, and diagnostic testing such as laboratory data and imaging. This is the forensic section of the note where the facts are noted without drawing any conclusion. For example, the description of this is not bunion, which is a diagnosis. A more appropriate description might be hallux abductus abutting the second digit with medially prominent first metatarsal head. Further objective description may include flexibility or rigidity, joint erythema, range of motion, and pain to palpation. Any exam finding can be described with just about infinite detail. So a concise description is best.
Also, avoid biased terms such as the ones listed here.
This slide and the next discuss a full adult review of systems. Note that this slide displays the content of the general physical examination excluding the podiatric, which we'll review in the next slide. This physical exam follows a regional approach, which differs somewhat from the average podiatric exam, which is more systems based. Note the full set of vitals including pulse oxygenation. Some now advocate pain as a vital sign, although this is more logically placed in the subjective section. Again, you can click on the chart icon to access and download these templates.
As mentioned before, the podiatry specific physical exam is often written in a systems format. Seen here are the vascular, dermatologic, musculoskeletal, and neurologic examinations. This order generally follows the actual examination sequence many podiatrists follow. Most commonly checking pulses comes first as we visually examine the patient, which covers the dermatologic and a portion of the vascular exam. We then continue with palpation and specific exam techniques for muscular and neurologic complaints. Charting in this manner will reflect the standard physical exam routine following a logical progression.
In this slide, I teased out the biomechanical exam from the musculoskeletal, but this might easily be combined without any difficulty. The same may be said for the gait exam and shoe gear inspection. Performing the physical exam in a standard repetitious manner every time will leave the chart note in an organized complete manner.
The assessment is your chance to finally state your opinion. Diagnoses or at least the differential diagnosis go in this section. Any staging or categorization would also be included here. For example, an assessment might be posterior tibial tendon dysfunction stage II. Associated diagnoses or contributing factors are listed here as well. Keep in mind the assessment must be supported by the rest of the document. For instance, you should describe an ankle contracture in the objective section if you're going to state ankle equinus as a diagnosis. The assessment should be clear and reasonable and provide a rationale for the treatment plan.
The final portion of any note is the plan. This section is often underdocumented by medical professionals and bears some discussion. The plan describes what treatment will be performed, whether it is education and counseling, written prescriptions, plans for surgical or non-surgical therapies, ordering x-rays and labs, or referrals to other specialists. A couple of points should be made. First, when prescribing medications, document your discussion of the possible adverse events, which you should be doing whenever prescribing a medication. Second, it's important for coding and billing purposes to document the face-to-face time spent with the patient. For instance, I might say 45 minutes was spent face-to-face time in counseling and education. Additionally, document the time period for the next followup, if any, and any specific plans for that next followup appointment.
Now that we've discussed the issues surrounding the medical documentation, let's get to the nuts and bolts of the specific document types. Here is a common case. You're consulted to come to the ER to see a patient. He is a 56-year-old Caucasian male whom you have never seen before, who presented to the emergency room two hours previously with the above pedal presentation. Two weeks ago he noticed clear drainage coming from a callus on the bottom of his foot. Since it didn't hurt he decided to watch the area, which subsequently became red and swollen and started draining yellow fluid. But since his foot remained painless, he didn't seek medical attention. Early this morning he noticed increasing pain and redness to his great toe and the arch of his foot. After further questioning he complained of chills the night before last. He presented to the ER this morning where the ulcer was debrided and the ER physician noted streaking with fluctuance around the arch. The picture doesn't show the ascending cellulitis of the medial arch extending to the tarsus. X-rays are ordered, which showed destruction of the hallux and a portion of the first metatarsal.
After seeing the patient, you decide to admit him and plan a trip to the OR. During our discussion of the chart documents for this patient, feel free to pause the lecture and read through at your leisure. The following slides are dense with text and I will not be reading these documents verbatim but instead will point out important sections. At the top corner of these slides you'll see a clickable picture, which will bring you to downloadable generalized templates. You're free to download and use these templates at your convenience.
This slide contains all of the components of the subjective section, but with a new patient history and physical or a new patient consultation note like this, the subjective and objective sections are exploded to allow an easier-to-read format. Others who read through this note can pick out the specific sections of interest without having to dig through the large subjective section.
The consultation note consists of a chief complaint, history of present illness, past medical history, allergies, medications, social history, surgical history, family history, and review of systems. Feel free to pause the slide and dissect the subjective consultation note section.
Here is the rest of our consultation note, which shows a preoperatively-oriented podiatry-specific physical examination, assessment, and plan. This slide has a lot of data, so pause the slide to read through the note. Because this patient is hospitalized and pending surgery, the physical exam is more detailed than a typical office exam. In this particular patient I'm concerned about complications of his lower extremity infection, including sepsis and findings that may increase the preoperative risk, especially cardiovascular, pulmonary, and cerebral risk, specifically the risk for MI, CVA, and PE.
This physical exam shows the patient is generally stable, is not mentally altered, is less likely to stroke, and has normal heart sounds. Although, if you look at the lab section, the patient does have ECG findings consistent with a prior MI. This note shows that you the physician are aware of the patient's heart disease increasing the risk of perioperative MI. Note also that the derm section describes our original picture.
The assessment lists the primary diagnosis, which is supported by the history and physical examination sections. Note also a judgment of severity and staging, namely the Infectious Disease Society of America's infection severity scale which has been noted, which supports the need for immediate operative intervention. The secondary diagnoses are indicated and our plan section delineates clearly what is going to happen as well as the postsurgical plan and involvement of other services. For those unaware of the term PARQ, this stands for Procedures, Alternatives, Risks, and Questions conference. This is a shorthand for obtaining consent. An alternative wording might be patient was consented for the above procedure, all risks, benefits, and potential complications of the procedure were discussed and all questions answered. How detailed your assessment and plan are is completely up to you, although clear and concise documentation is quicker for you and less cumbersome for others to read.
Since we're talking about medical documentation, I'm going to take a moment to discuss the consent note. Discussing the consent process in detail is beyond this lecture, but let's review the highlights.
First, remember to add all surgical options to your consent form. For example, if you're planning an arthroscopic ankle synovectomy, be sure to write possible open if there is a chance this might happen. In our case your consent might say something like incision and drainage with first ray resection left foot. In parenthesis you might state in layman's terms (removal of big toe and metatarsal bone and all non-viable tissue). This gives you the freedom to do what's necessary for the patient. Remember that the goal of the consent process is not simply to have the patient sign a permission slip.
Your patient needs to understand what's going to happen, the procedure, what the risks of the procedure are to him or her, what other treatment choices are available, and what the benefits are to doing this procedure. Whenever possible, diagrams are highly useful when consenting patients. This is also a good way to improve medicolegal protection. A litigious patient will often have difficulty arguing they didn't understand the procedure if they signed off on a diagram. In short, they need to understand the ramifications to them as a result of their surgery. Good doctoring requires your patient to understand these issues, not just sign a piece of paper.
You've now completed your procedure, which went well. During the procedure you found an abscess in the patient's medial arch and bony changes of the first ray consistent with osteomyelitis. You flushed out the wound, removed all visibly non-viable bone, and sent it to pathology, took a clearance fragment of bone to be sure you didn't miss any proximally infected bone, took cultures, and placed antibiotic beads and a negative pressure therapy device to the wound. The patient is admitted to the hospital for empiric IV antibiotics, observation, and possible return to the OR for further debridement if necessary.
Here is your postop note. You'll see in a few minutes this is essentially the same format as the first part of the operative report. In my opinion, there is one reason for this note - to communicate the basic facts about the procedure to other staff members handling your patient postoperatively. Consider for a minute why this information would be important in the first few postop days before an operative report enters the chart. Other members of the medical team will want to know who did what procedures so they know whom to contact in a pinch. They'll also note from your note that a specimen went to the pathologist in the lab, so reports should be entering the chart within the next few days.
Other physicians can be on the lookout for postop complications as long as you've documented well. For instance, symptoms of postop anemia can be explained by excessive blood loss. Or, if your patient unexpectedly became hypertensive during the surgery, the internal medicine team will be aware and monitor and treat this accordingly. This is also a good time to communicate the patient's disposition - are you planning a return to the OR tomorrow or is your patient going home? Other members of the staff such as discharge planning and physical therapy will understand the plan as long as you communicate it effectively in a postop note.
In some areas around the country you may be the admitting doctor. In other cases your patient might be admitted to the internal medicine service or their PCP. In most cases of patients with complex medical comorbidities, you would at least consult someone to medically manage the patient. But for the sake of completeness, we'll go over the admission orders for your postoperative patient.
The contemporary format and mnemonic is termed ADCVANDILMAX, which is diagramed here and read. As hospital charts become increasingly template driven, this format which would be handwritten is being used less often. However, this format remains important if for nothing else it limits the chance of omission of important orders due to faults in memory. Remember, for anything unclear or omitted, the floor nurses are going to call you for clarification. For the sake of brevity, I left out the specific medication orders, but keep in mind the med orders generally consist of p.r.n. and scheduled medications.
Now that your patient is safely on his way to the surgical ward, you can dictate your operative report. Most students, interns, and residents are very nervous while dictating the first few times. I'd suggest keeping a written template of an operative report in your lab coat and refer to it until you memorize this. There's an art to dictating a concise and clear op report that takes practice. Residents should keep copies of their operative reports for learning purposes, but be careful about HIPPA. Check with your chief resident or residency director about this. Remember, the operative report is simply a narration of what occurred during the procedure. The level of detail is up to you, but there is an appropriate amount of detail that takes time to learn. Remember also that your note should discuss your rationale and support what you actually did during the procedure.
The overall structure of the report is broken up into two parts. The initial information, which is exactly the same as the initial postop note, the SAPPPPAHEMI, and the procedure narration. The beginning and ending parts of the narration are pretty consistent no matter what procedure you're doing. The middle part is what varies. Click on the book in the upper right for a generic template. The first part again is the mnemonic SAPPPPAHEMI. Look back at the postop note for this. The second part is the operation and findings. In some cases you might choose to add a findings section after the SAPPPPAHEMI if you have significant findings to communicate to others. This is especially important in tumor surgery, infection, and cases with unexpected findings or when you're staging something such as an ankle arthroscopy. Appropriate detail is important, but you don't have to go overboard. No one wants to read that you've incised the skin with a #10 blade. Instead, mention the location and size of the incision. Be sure to mention specific anatomic structures you're protecting or avoiding. For example, with lateral ankle surgery it's important to mention you've avoided the sural nerve. On the other hand, if you're forced to cut a nerve, then mention it and why. For example, while doing a Lapidus procedure, there's often a communicating nerve from the medial dorsal cutaneous nerve that may be sacrificed. It's okay to mention it. Simply justify your decision process.
Mention at the end any specific dressings like a Jones compression dressing and any alterations to standard physicians. For example, after a lateral ankle stabilization, you might state the extremity was splinted in eversion and dorsiflexion. State any intraoperative complications and how they were resolved and the disposition of the patient.
At this point, it is postoperative day #2 and due to your hands of gold and immaculate clinical skills, your patient is recovering beautifully. He's doing much better with resolving infection and improving general clinical signs and labs. His blood sugar and blood pressures are well controlled. Preliminary blood cultures are negative and your preliminary intraop cultures showed a mixed 3+ Gram-positive cocci in clusters. Final cultures and sensitivity are not yet available. A PICC line has been placed for outpatient antibiotics. Your plan is to discharge your patient tomorrow with IV antibiotics, local wound care with negative pressure therapy, and off-weighting to obtain granulation with subsequent possible skin grafting.
Here is your followup note in SOAP note format. This SOAP note is lower extremity specific, though on my hospitalized patients I always examine cranial nerves, heart, lungs, and abdomen looking for postoperative complications. The review of systems is incorporated into the subjective and reviews possible complications. For example, a pulmonary embolism might present as orthopnea, chest pain, shortness of breath, and hemoptysis. The vitals are listed with the most current findings and include a current temp and maximum overnight temperature. The objective section describes the findings including dressing appearance and the contents of any attached devices such as drains. The assessment and plan sections state your opinion on how things are going and your short and longer term plans.
Many services, especially internal medicine who may be dealing with multiple diagnoses, will combine the assessment and plan sections stating in bulletin format one assessment and treatment plan, then moving to the next. This method prevents confusion when dealing with multiple medical problems.
Again, for the sake of discussion, let's assume now the patient has been admitted to you with medical management by the internal medicine service. So it's your responsibility to actually discharge the patient and dictate the discharge summary. Almost all hospitals now use templates for their discharges, so we will skip over the specifics of the discharge orders and focus on the discharge summary.
The main purpose of the discharge summary is just like the operative report, a narration of the events that occurred while the patient was admitted. This includes the dates of admission and discharge, the primary and secondary diagnoses, admitting service, and referring doctors, consultations, procedures, and abbreviated history and physical, the course of the patient's hospitalization including any complications, what condition the patient was in at discharge, hopefully good, the plan for followup, any medications and instructions. Be sure to carbon copy to everyone who has a stake in the patient.
Almost everything we've discussed thus far has assumed the use of a paper chart. However, as electronic medical records become increasingly common and affordable for more facilities, increasing portions of the patient's chart will be listed electronically. In some cases, like the VA Health System, the entire chart is online. This is mostly beneficial and improves efficiency by creating templates which rapidly import data, but the tendency in my experience has been to see charts inundated with useless information that has less to do with the current complaint making reading through these notes rather tedious.
For those using EMR systems, the same principles apply as with the use of paper charting. Clear concise notes that communicate important data about your patient are the most effective. Another charting method available, which most current residents are likely to come across, especially during emergency room rotations, is the T-sheet or template sheet. This is a pre-made document that lists the important chart sections in a checklist and short fill-in space format for rapid data acquisition. These sheets are available for many body systems and complaints. T-sheets function as another method of rapidly acquiring information in an easy-to-read format based on a specific complaint such as a lower extremity problem seen here. Other T-sheet topics might cover chest pain, abdominal pain or other varied complaints.
In conclusion, medical documentation can be another tool to improve patient care and safety. It can also become a significant source of error and danger to your patients. I hope our discussion will help improve the already high-quality care our patients currently receive. In closing, here are a few points to emphasize from our discussion. The chart documents what occurred during a patient's interaction, chart the facts, avoid charting interpersonal issues and derogatory remarks, write legibly, clearly, and remember the three C's - be clear, concise, and complete. It's all about effective communication.