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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

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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
slide5
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
slide7
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)
slide9
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
slide10
H & P
  • Other –
    • Lab
    • X-ray
    • Other studies
    • Old record review
slide11
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
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