A Briefing on Electronic Progress Notes. Lynn Jacobs Svetlana Yedreshteyn Organizational Development & Learning July 15 th , 2009. Electronic Progress Notes. Current method is going away Progress notes, to date, have been inadequate and, at times, dangerous. Inconsistent Documentation.
Organizational Development & Learning
July 15th, 2009
A patient acutely deteriorates and codes. He is admitted to the MICU and his wife is called. Upon hearing he is in the ICU on a ventilator the wife asks why we didn’t follow his living will. The patient’s end of life wishes were documented on a prior admission but not in the current chart. Additionally, while the attending knew the patient’s wishes, the information was not included in a progress note.
Patient is admitted to the PACU after major abdominal vascular repair. Pulses at the end of the case are absent in both lower extremities. The surgeon expects pulses will return in the immediate post-operative period but does not document this or document a clear follow up plan. Nursing and surgical residents accept the patient’s absent pulses as expected and do not call the attending when the patient’s extremities deteriorate from lack of blood flow. When the attending returns to see the patient there is myonecrosis and bilateral amputation is indicated. Family declines the procedure and patient goes on to die.
Patient’s AICD is turned off in the OR but not documented. Verbal report is given to the PACU that the AICD is off. RN questions resident who says it’s OK to transfer the patient. Resident says no problem as she is sure someone would have told her if she needed to turn the AICD back on. Patient is transferred to the floor and sustains a V-tach arrest that is caught on telemetry in a timely manner. The AICD had not been turned back on.
Pt states that he feels well. No SOB, states that he feels no pain in his leg, and has been walking around with PT. O: no events overnight.
Gen: lying in bed, NAD
Pulm: coarse breath sounds, no crackles
CV: S1S2+, no M/R/G, irregularly irregular rhythm
Abd: soft, NT/ND, BS+
Ext: legs no longer edematous, erythema over RLE approximately same as yesterday.
Lab Results Section
White Blood Cells 8.1
Nucleated RBCs 0
Red Blood Cells 2.71
Absolute Neutrophils 5.3
Absolute Lymphs 1.4
Absolute Monocytes 0.9
Absolute Eosinophils 0.4
Absolute Basophils 0.1
90M h/o CHF, COPD (on home O2), HTN, CRI (baseline Cr 2.2-2.6), BPH, hypothyroid, PAF, p/w RLE pain x1day. In ED, febrile to 102, in Afib with HR of 110. Pt received 500 cc NS bolus and IV dilt in ED, RLE found to be edematous, swollen; likely cellulitis. LE duplex negative, BCx positive for Acinetobacter in 2/2 bottles, sensitive to Unasyn, Cipro. Sputum Cx pos for MRSA.
ID - cellulitis, Acinetobacter bacteremia
- leg improving slowly, seems to continue to improve off Abx
CV - CHF, PAF
- will continue to monitor I/O's, daily weights
- continuing Lasix 40 mg PO q12h
- continuing norvasc 5 mg daily
- pt breathing well, will cont chest PT and nebs endo
- TSH normal, continuing synthroid at current dose
- continuing insulin sliding scale for hyperglycemia
- urine albumin:creatinine ratio elevated
- continuing proscar, flomax
- anemia w/u consistent with iron deficiency, but anemia is macrocytic with normal RDW; B12/folate normal, will give iron PO
- heme consulted, will f/u on recs for rest of MM/lymphoma workup as outpt (BMBx)
- DVT: HSQ 5000 units Q8H
- on PPI, will attempt to determine why
- plan to D/C home with services on 9/19, tomorrow if okay with heme - will attempt to reinstate
- appreciate rehab consult recs
- full code.
Handwritten attending notes stated not iron deficiency
No events overnight. No dyspnea. Ambulating.
(input from ICIS)
Pulm: Unchanged from prior (Coarse BS)
Ext – Unchanged from prior (RLE erythema, no edema)
Notable for normocytic anemia and thrombocytosis
Stable renal insufficiency
No other diagnositic tests
Rehab and Heme consults noted and appreciated. Heme eval to be completed as an outpatient
Cellulitis with Acinetobacter bactermia– better
Monitor off antibiotics; skin care
CHF Diastolic – acute-on-chronic – better
Continue furosemide 40mg PO q 12 hours
Afib – unchanged
Anemia – acute – unchanged
Follow up with hematology as outpatient for further eval
COPD – chronic – unchanged
Continue O2 via nasal canula, chest PT
HTN – chronic - unchanged
Chronic renal insufficiency – unchanged
Hypothryoidism – chronic – unchanged
Stable on current synthroid
Risk for DVT – acute – unchanged
Continue SC Heparin 5000U Q8
Goals towards discharge
Ambulatory on oral meds with home services in place
Progress toward meeting discharge goals
Awaiting home services
Interval History is the first section of the progress notes for attending MD, fellow and medical student
Hovering over book icon will display reference of document, date, time vital sign values where entered.
Automatically retrieves most recent vital signs entered by nursing & others.
Looks back 48 hours, otherwise it’s blank. You can enter vital signs taken by you.
If there is no change from previous day, then select “retrieve previous data”; text box will auto populate with previous data
(if any) entered by AUTHOR.
If Lab Results are reviewed, additional selections display and becomes mandatory.
Comments text box also displays.
Text box for Other Diagnostic comments and becomes mandatory.
Multiple selections allowed plus a type in space for others. and becomes mandatory.
If worse, unchanged or better is selected, data will persist until it is resolved or ruled out.
Plan is always blank. Selecting ‘Previous plan remains the same’ will auto populate previous data (if any) entered by AUTHOR.
Text boxes will be populated by most recent data ( if any) entered by AUTHOR .
Attending MD’s progress note statement of collaboration/supervision
PROGRESS NOTES MEDICINE collaboration/supervision
Effective July 1, 2009, the Medicine Service will enter all progress notes in ICIS.
This initiative moves us closer to the goal of achieving a paperless environment and above all, improving the quality of our documentation.
The structured progress note has been configured to each specific role for the Medicine Service (e.g. an attending or fellow’s note will NOT have a hospital course entry whereas the resident/interns note will). Eventually, other services progress notes will also be configured specifically to each service.
Please note that manual copy forward will be suppressed in the new progress note. To expedite note completion, the system will copy forward predefined sections of the exam, problem list, and discharge criteria.
It is highly recommended that you start the process of documenting care for the patient by viewing documentation done by other clinicians the previous 24hrs (or greater), via the Clinical Summary Tab. Selecting Physician View will display VS, Current Medications, Lab Results, Other Ancillary Results, Consult Notes and Progress Notes. From the Progress Note tile, you have the option of viewing the content and or enter a new note.