jacobi ambulatory care service why write outpatient notes? susan dresdner, m.d. eleanor weinstein,...
TRANSCRIPT
JacobiAmbulatory Care Service
Why Write Outpatient Notes?
Susan Dresdner, M.D.Eleanor Weinstein, M.D.
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Why Write Notes?The Positive Reasons
• Communication–Other MD’s (consultants, interim visits, ED)
–Professional staff (nurses, social workers, dieticians)
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Why Write Notes?The Positive Reasons
• Organization: highlights abnormals, helps keep thoughts clear
• Record-keeping: keep track of each diagnosis, follow symptoms, prior drug/antibiotic use
• Memory cues• Clarify intent/ thought process• Interpretation
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Why Write Notes?The Negative Reasons
• Medico-legal: chart is legal document
• Evidence of events and intentions
• Billing• Document
supervision
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As Many Occasions for Writing Notes As There Are For Seeing Patients
Outpatient Notes• Routine clinic visit• Walk-In • Medical consultation• Other contact (phone call,
etc.)• Procedure
Inpatient Notes• The Admission Note• The Daily Progress Note• The Coverage Note• The Procedure Note• The Transfer Note• The Code Note• The Death Note
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Routine Ambulatory Care Visit Note
• All notes are written in the computer• Who gave history? Who is present? Was
interpreter used (use language line for all translation and document interpreter ID)?
• Must obtain Social History!• Address adherence• Assessment = Differential Diagnosis. THINK!• Clear management plan
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Routine Visit Notes: “SOAP” Notes
• Subjective
• Objective
• Assessment
• Plan
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“Subjective”
• In the patient’s own words: – What does patient tell you about how
he is feeling?
– How is the disease process affecting the patient?
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“Objective”
• How do you perceive the patient– appearance
– physical exam (it is NOT okay to say “PE unchanged!)
– Document BP’s in separate field
– laboratory data
– medication
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“Assessment”
• The MOST IMPORTANT part of the note, usually given the least attention
• Summary of the situation• How do you put all of the information together?
– Analysis of all of the data including consultant opinions– Address all abnormal exam and lab findings
• Organize by organ system or problem• What do you THINK?
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“Plan”
• How are you going to handle each of the identified problems?
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• Acknowledge and address all labs since last visit, no need to copy all labs over
• Acknowledge all notes from consultants
• Must have “Healthcare Maintenance” section in plan
• End note with “Case discussed with Dr. _______”
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A Sample Progress Note
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A Sample Progress Note, con’t
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Procedure Notes
• What procedure? What indication?• Begin with “after informed consent was
obtained….”• Describe procedure in detail• “Pt. tolerated procedure well”• Any necessary f/u tests• Who supervised
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Transfer Notes (to ER, Psych ER)
• No patient may be transferred without full note in the computer!
• Must discuss reason for transfer and plan
• Notify accepting service and acknowledge this in note
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Consultation Notes
• Indicate reason for consultation
• Full history and physical exam
• Assessment of situation and recommendations
• Plans for further evaluation
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Ten Commandments of Outpatient Note
WritingWrite coherently
Do not write “scrolling notes”
Acknowledge all other notes before yours
Acknowledge data
Document all pt. encounters
Analyze
Plan
Document healthcare maintenance
Remember your attending who discussed the case
Do not wage war in chart
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