Hospital documentation
Download
1 / 24

Hospital Documentation - PowerPoint PPT Presentation


  • 54 Views
  • Uploaded on

Hospital Documentation. H & P Admit Note Admit Orders. History and Physical. …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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' Hospital Documentation' - muriel


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Hospital documentation

Hospital Documentation

H & P

Admit Note

Admit Orders



Is the full work up
…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


Soap format
SOAP format

  • Objective – what do YOU find?

    • Physical

    • Lab

    • X-ray

    • Other studies

  • Assessment

  • Plan


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


H p cont
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


ROS

  • Integument/Skin

  • HEENT

  • CV

  • Pulmonary

  • GI

  • GU

  • Neurologic

  • Musc/Skeletal

  • GYN

  • Endocrine


H p cont1
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)


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


H & P

  • Other –

    • Lab

    • X-ray

    • Other studies

    • Old record review


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..)


Assessment e g
Assessment, e.g.

  • Pneumonia

  • Hypokalemia

  • HxHTN (or can say HTN – controlled)


Plan what are you going to do with the patient
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)



Admit note
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


Must contain
…MUST contain

  • CC

  • Hx cc

  • Pertinent physical (pertinent positives)

  • Assessment

  • Plan



Instructions to the nursing staff
…Instructions to the Nursing Staff

  • What do you want done for this patient now that they are coming into the hospital?

  • Systematic approach


Admission orders1
Admission Orders

  • Admit to service of (insert doctor)

    • Any special floor? (ICU, stepdown, telemetry)

  • Condition

  • Allergies

  • Vitals

  • Activity

  • Diet


Admission orders2
Admission Orders

  • Medications IV

  • Medications PO

    • These include any over the counter as well

  • Labs

  • X-ray

  • Other studies

  • Other


So for our pneumonia
…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


Pneumonia cont
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


Pneumonia cont1
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



ad