Download - Hospital Documentation
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Hospital Documentation
H & PAdmit Note
Admit Orders
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HISTORY AND PHYSICAL
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…is the FULL work up• SOAP format
• Subjective – What is the patient telling you?• Chief Complaint• History of Chief Complaint• Review of Systems• Past medical history• Past surgical history• Family history/social history• Allergies/meds
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SOAP format• Objective – what do YOU find?
• Physical• Lab• X-ray• Other studies
• Assessment• Plan
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H & P • Chief Complaint
• CC• If using patients’ words, use “quotations”• Ok to summarize
• History of Chief Complaint• HCC or HxCC or HxPI• “quotations” if using patients’ words• Note if history is coming from someone other than the
patient themself
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H & P cont.• Past medical/surgical history• Review of Systems
• ROS• Pertinent positives AND negatives• Get into a “flow”
• Is ok to have cheat sheets
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ROS• Integument/Skin• HEENT• CV• Pulmonary• GI
• GU• Neurologic • Musc/Skeletal• GYN• Endocrine
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H&P cont• Family History/Social History/Job/Religion
• Include habits here – smoking, alcohol, drugs• Medications
• Don’t forget over the counter, vitamins and herbal supplements• Need to ask – most patients don’t consider these “meds”
• Allergies• And what is the actual allergy (so you can distinguish
from a side effect)
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H & P• Physical Exam
• Again, use a logical flow• ALWAYS start with vital signs
• BP, pulse, resp, temp, height, weight• OK to use cheat sheet here as well• Chart pertinent positives and negatives• Don’t make up acronyms
• RRR is standard c/r/g/m/ is NOT
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H & P• Other –
• Lab• X-ray• Other studies• Old record review
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H & P• Assessment
• What does your physical and the lab, etc., lead you to find?• Ok to use symptoms if don’t have full diagnosis
• DON’T use the OSCE format• No need to put 4 diagnoses here
• If they have a history of something can put it here, but should NOT be the first listed• (and you want to make sure state Hx of..)
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Assessment, e.g.• Pneumonia• Hypokalemia• Hx HTN (or can say HTN – controlled)
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Plan – What are you going to do with the patient?
• Admit• Start IV antibiotics• Replace electrolytes (correct electrolytes, etc)• Consult Pulmonary – anticipate
bronchoscopy• (ok to write see orders)• Ok to write discussed the case with Dr. X
(seen with Dr. x present, etc)
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ADMISSION (ADMIT) NOTE
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Admit Note• What you put as your first progress note• Abbreviated version of H & P• Can be the full H & P
• Entitle “Admit/H &P”• No need to duplicate
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…MUST contain• CC• Hx cc• Pertinent physical (pertinent positives)• Assessment• Plan
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ADMISSION ORDERS
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…Instructions to the Nursing Staff• What do you want done for this patient now
that they are coming into the hospital?• Systematic approach
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Admission Orders• Admit to service of (insert doctor)
• Any special floor? (ICU, stepdown, telemetry)• Condition• Allergies• Vitals• Activity• Diet
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Admission Orders• Medications IV• Medications PO
• These include any over the counter as well• Labs• X-ray• Other studies• Other
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…so for our pneumonia• ATSO Dr. Gail Feinberg• Condition – stable• NKDA• Vitals (q 4 hours, q shift)• Activity –
• ABR with BRP (Absolute Bed Rest with Bathroom Privileges)
• Ambulation with assistance, no limitations, etc
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Pneumonia cont• Diet – regular as tolerated (1800 cal ADA,
salt restricted, cardiac – check with hospital to see how these are categorized)
• Medications• IV – 1000cc D5W.5NS с 40meq KCL/liter @
75cc/hr• Rocephin 1gm IV daily (DO NOT USE qd)• Xopenex nebs q8 hrs
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Pneumonia cont• Labs
• Blood Culture prior to first dose IV antibiotic, sputum culture, CBC, CMP
• CXR – PA and Lateral• Other
• Oxygen per protocol (2liters NC, only at hs…)• Chest percussion after neb treatments• Incentive spirometry q shift
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Questions?