Charting and Medical Notes

History and Physical

Begin with the patient profile

 

Patient Identifiaction (ID)

RFC

 

Past Medical History PMHx

if possible, list baseline lab values and diagnostic test results

 

HPI

Include what is relevant to the presenting symptoms

sometimes it is good to use the patient's words

review of systems for what is not relevant

include pertinent negatives

 

Medications

try to outlon what each is for

if the patient doesn't know them, try to get in touch with the GP/pharmacy

allergies

 

FmHx

SHx

PE

vitals

HEENT

neuro

CV

resp:

Investigations

Assessment

Plan

Assessment and Plan

 

Problem List

For each problem, come with with relevant information, concerns, and plan

 

SOAP notes

track patient progress

allows communication with consulting services

clearly describes daily plan made by team

 

Subjective

focus on symptoms pt had since presentation; document any new symptoms and review events since overnight.

often us patient's words

 

Objective

transcribe vitals and relevant labs and diagnostic results

do not need to do a full physical exam - focus

 

Assessment and Plan

can also combine into a problem list

end with disposition: how long they'll be in hospital, followup plan, etc

 

Physician Orders

Physician orders are legal documents. Write legibly and use black ink to help with scanning records.

Ensure all order sheets have the patient's full name and unit number.

STAT order must be written and verbal

 

Do not scratch things out and try to fix the mess - medication errors are bad news! If you make a mistake, start a new line.

 

Addressograph: least amount of information is name and hospital number

date year, month, day

time stamp everyting!

 

list allergies at the top of the page

print your name, designation, and pager number, and sign the order sheet.

Have the orders co-signed.

 

Diagnosis

 

 

Diet

ie NPO

 

Activity

ie as tolerated

 

Vital Signs

ie Q4H

 

Investigations

ie CBC, Lytes, BUN, CR, glucose daily x2days, then reassess

ie abdominal X ray in the AM

Intravenous

maintenance IV

(1.5-2ml/kg/hr for adults)

 

replacement IV:

ie .45% NaCl with 10 mEq KCl/L to replace NG losses ml:ml q12h

 

Intake and Output

ie monitor intake and output q12h

Drugs

drugs, dose, route, and frequency

Prescriptions

 

Fill in the full information.

Pharmacists now keep track of messy prescriptions and report them...

 

Write the p

 

dermatology prescription

concentration, ointment/cream, how often

 

estimate body surface area affected (rule of 9's)

• head 9%
• arms 18%
• trunk 36%
• legs 36%

30 grams is what you need for entire body

 

 

Discharge Summary

 

 

 

TAT is now ~2-3 days for CDHA transcriptionists

 

Administrative Data

• hospital number
• patient name
• admission date
• date of discharge
• operative date
• health card number
• date of birth
• name and address of people who should receive a copy (family, GP, others)

Clinical Data

• admission and discharge diagnosis; co-morbidities
• HPI, including medications and allergies
• relevant past medical history: review of systems and relevant operations
• physical examination (including growth percentages for children)
• relevant lab data: standard and other tests
• course in hospital: highlights
• overall health and fuctional status at time of discharge
• recommendations on discharge
  • number and be specific!
  • recommendations for monitoring and follow-up
  • if subsequent appointments have been made or needed
• information given to the family
• medications on discharge: list in numbered format

 

Dictation tips:

spell out uncommon drugs and diseases

avoid abbreviations when possible

emphasize words such as inter/intra, hypo/hyper

15 and 50 can be quite confusing - read out the numbers

do NOT chew gum while dicating