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EVERYTHING YOU EVER WANTED TO KNOW ABOUT NOTES
I.E. INTRODUCTION TO DOCUMENTATION SO DEBORAH MACK WILL LEAVE YOU ALONE SO YOU CAN ANSWER OTHER NON-EMERGENT PAGES
Bill Beck with a fist-bump to Rondi Kauffmann MD, MPH7.2.2010
H&PReferring physicianCCHPI (4+)PMHPSH MedicationsAllergiesFamily HistorySocial History
H&PROS (10+)
List by systemOr, state “10 systems were reviewed and were negative except for…”
Exam (8+ systems)VitalsLabs
RadiologyPathologyAssessmentPlan
H&PHPI elements:
LocationQualitySeverityDurationTiming ContextModifying FactorsAssociated signs and symptoms
H&PROS elements
Constitutional-fever, weight lossEyesEars, Nose, MouthThroatCVRespiratoryGIGUMusculoskeletalSkinNeuroPsychHeme/lymphAllergic/immunologic
H&PExam elements:
ConstitutionalEyesEyes, Nose, Mouth, ThroatCVRespiratoryGIGUMusculoskeletalSkinNeuroPsychHeme/lymphatic
CLINIC NOTEFull H&PFollowup clinic visit
Chief complaintInterval history New labs/imagingExam (8 organ systems)AssessmentPlan
CPT Code 99241 99242 99243 99244 99245History (3 of 3)
HPI 1 - 3 1 - 3 4+ 4+ 4+ROS None 1 2 - 9 10+ 10+PFSH None None 1 All 3 All 3EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems 8+ systems
Decision (2 of 3) Straighforward Straightforward Low Moderate High#Dx/Options 1 1 2 3 4
Amt. Data/Complex 0 - 1 0 - 1 2 3 4Risk Level Minimal Minimal Low Moderate High
TIME 15 minutes 30 minutes 40 minutes 60 minutes 80 minutes
CPT Code 99201 99202 99203 99204 99205History (3 of 3)
HPI 1 - 3 1 - 3 4+ 4+ 4+ROS None 1 2 - 9 10+ 10+PFSH None None 1 All 3 All 3EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems 8+ systems
Decision (2 of 3) Straighforward Straightforward Low Moderate High#Dx/Options 1 1 2 3 4
Amt. Data/Complex 0 - 1 0 - 1 2 3 4Risk Level Minimal Minimal Low Moderate High
TIME 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes
CPT Code 99211 99212 99213 99214 99215History (3 of 3)
HPI 1 - 3 1 - 3 4+ 4+ROS None 1 2 - 9 10+PFSH None None 1 2EXAM 1 Area/System 2 - 4 systems 5 - 7 systems 8+ systems
Decision (2 of 3) Straightforward Low Moderate High#Dx/Options 1 2 3 4
Amt. Data/Complex 0 - 1 2 3 4Risk Level Minimal Low Moderate High
TIME N / A 10 minutes 15 minutes 25 minutes 40 minutes
Elements of HPILocation Head, Face Constitutional-fever, wt lossQuality Neck EyesSeverity Chest, Breasts, Axillae Ears, Nose, Mouth, ThroatDuration Abdomen CardiovascularTiming Genitalia, Groin, Buttocks RespiratoryContext Back, Including spine GastrointestinalModifying Factors Each Extremity GenitourinaryAssociated Signs and Symptoms Musculoskeletal
IntegumentaryNeurological PsychiatricEndocrineHematologic / LymphaticAllergic / Immunologic
Constitutional (vital signs, etc.) Respiratory SkinEyes Gastrointestinal NeurologicEars, Nose, Mouth, Throat Genitourinary PsychiatricCardiovascular Musculoskeletal Heme/Lymph/ Immunologic
CLINIC CONSULT (3 of 3)
CLINIC NEW PATIENT (3 of 3)
Organ Systems for Exam
CLINIC ESTABLISHED PATIENT (2 of 3)
Reserved for non-hospital
based practice
Systems for ROSBody Area for Exam
DAILY PROGRESS NOTEName of procedure, post-op daySubjectiveVitalsPhysical exam
Document 5 organ systemsLab and microbiology dataMedications, i.e. antibiotic day #1Assessment
diagnosesPlan
FROM CATHY HALSEY……“As a coder/billing person, I don’t need the past history carried over (cloned) each day. Instead, I need to see what happened since the last note, what your concerns are for the day, is the patient’s condition stable, improving or declining and if you plan to order additional testing, surgery, etc.”
SICU NOTEName of procedure, post-op day24 hour eventsSubjectiveVitalsDripsVentilator settingsPhysical ExamLabs and microbiology data
SICU NOTEAssessment and plan
NeuroCVPulmonaryFEN/GIRenalHemeEndocrineIDProphylaxisOther-lines, catheters, dispo
IMMEDIATE POST-OP NOTE- STARFORM
Start/stop timePreoperative diagnosisPostoperative diagnosisSurgeonAssistantsAnesthetic techniqueImportant findingsComplicationsDrainsFluid managementEBLPatient disposition and conditionSpecimens
OPERATIVE NOTEPre-op diagnosisPost-op diagnosisSurgeonAssistantsOperative procedure performedAnesthetic techniquePre-op indications for procedure
OPERATIVE NOTEProcedure
PositioningIncisionFindingsTechniqueType of closureDrains
ComplicationsSponge and needle countsFluid managementEBLPatient disposition and condition at end of case
POST-OP CHECKGoal: Identify potential problems earlyRationale: Immediate post-op period is a time of significant physiologic stressSequence:
Introduce yourself, ask how they are Check vital signsAsk specifically about the following:
POST-OP CHECKPainChest painSOB
Did they have a post-op CXR?Nausea/vomitingOperation specific problems:
Carotid endarterectomy: BP control, neurologic compromise, neck hematomaThyroid/Parathyroidectomy: neck hematomaGastric bypass-tachycardiaVascular-pulse exams
POST-OP CHECKExamine patient
Heart/lungs/operative siteDrains- nature and output
Review post-operative ordersPain medsAnti-emeticFluidsGI prophylaxis/ DVT prophylaxisIS to bedside
Review post-op labsAnswer patient questions
POST-OP CHECK ‘DON’TS’Don’t relate operative findings unless discussed with senior residentDon’t ignore warning signs or complaints. Get appropriate workup or call senior resident if unsureDon’t transfuse, give diuretic, or change diet without checking with senior residentDon’t forget to write a post-op note in the chart.
DISCHARGE SUMMARYAttending surgeonDate of admissionDate of dischargeDiagnosesProcedures performedHistory/physical exam/labs on admissionHospital courseDischarge instructions
MedsFollow-upActivityDietStudies
Condition at discharge
ACUTE EVENT NOTEBackgroundSituation upon arrival
Who presentVitalsPatient conditionExam
Actions takenPatient responseFinal dispositionInform attending and senior resident
DEATHDeath Note
Date of admission/deathFloor/unitCause of deathDiagnosesAnticipated?Medical Examiner’s case?Hospital courseAutopsy requested?Family member notified
Inform medical examinerCertificate of DeathInform familyInform attending
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