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Do I have to document that?. Pam Shaw MD. Documentation. Hospital H&P Daily Notes Procedure Notes Discharge Summary Off-service Notes Orders Consults. History and Physical Format. History. Physical exam. Vital signs General HEENT Lungs CV Abdomen Musculoskeletal Neuro

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  • Hospital
    • H&P
    • Daily Notes
    • Procedure Notes
    • Discharge Summary
    • Off-service Notes
    • Orders
    • Consults
history and physical format
History and Physical Format


Physical exam

Vital signs








Assessment or Problem list


  • CC
  • HPI:
  • PMH:
    • Meds:
    • Allergies:
  • SH:
  • FH:
  • ROS:
what makes a good note
What makes a good note
  • Legible with legible signature/printed name
  • Order – SOAP or H&P
  • Relevant positives and negatives
  • *Demonstrates your understanding*
  • Matched assessment and plan
  • Accurate record of visit
  • Clear to an outsider what was going on
what makes a bad note
What makes a bad note?
  • Illegible
  • Disordered
  • Containing personal biases/beliefs (yours)
    • Advised that (some behavior) is wrong
  • Inaccurate or misleading
    • I listened to the heart yesterday – nothing changed
    • Neuro exam – WNL
    • Check boxes on electronic health record
yes this was actually written
Yes, this was actually written…
  • She has no rigors or chills, but her husband states she was very hot in bed last night.
  • The pelvic exam will be done later on the floor.
  • She stated that she had been constipated for most of her life until she got a divorce.
  • On the second day the knee was better and on the third day it had completely disappeared.
  • Between you and me, we ought to be able to get this lady pregnant.
what about this
What about this…
  • Patient is non-compliant with medications
  • Previous physician did not order an XRay
  • General rule: Nothing you wouldn’t show the patient.
  • Did not take meds due to concerns about safety.
sometimes it is hard
Sometimes it is hard…
  • Patient refuses to consider smoking cessation even though I told her that is causing her child’s asthma.
  • Discussed risks of smoking concerning child’s asthma. Patient voiced understanding and is pre-contemplational.
hpi items locates
  • Location:
  • Other symptoms:
  • Chronology:
  • Alleviating factors:
  • Things that make it worse/better:
  • Experience/Quality of the symptoms:
  • Severity:
note writing
Note Writing
  • Daily notes should be organized so that they are brief, yet highlight important data and clearly express clinical impressions.
  • The basic format is referred to as a SOAP note. This stands for the major categories included within the note: Subjective information, Objective data, Assessment, and Plan.
note writing11
Note Writing
  • The data presented should be factual. Old events that were described in earlier notes should not be repeated. The daily note is not meant to be a recap of the H&P.
  • The impression and plan generally reflects the thoughts of the entire team.
note writing12
Note Writing
  • Don't take hours to write a note. Make sure that you get feedback from team members about your written work.
  • Certain services have very particular styles, emphasizing aspects that are important to the care that they provide.
example patient with pneumonia
Example-Patient with Pneumonia

Hospital Day # 3

  • S: Patient feeling less short of breath, with decreased cough and sputum production.
  • O: Maximum Temperature: 101.5 (yesterday 103)
  • Pulse: 80-90
  • BP: 110-120/70-80 RR: 20-24 Sat: 95% 2l O2 (yesterday 95% 4l O2)
  • I/O: 2.5 L IV, 1 L PO/ UO 2L, BM x 1 Wt 140 lbs (no change from yesterday)

Day # 3 Ceftriaxone, 1g IV BID

PE: No JVDLungs: Crackles and dullness to percussion at Right base with egophony; no change consistent with yesterday C/V: RRR without murmurAbd: soft, non-tender , positive BSExt: no edema

note continued

Labs: Sputum and blood cx still negative; otherwise no new data


1) Pneumonia: Right LL pneumonia. Responding to IV Ceftriaxone, with decreasing O2 requirement and fever curve. Also feeling better. No evidence of complications. Plan:

  • IV abx x 1 additional day then change to po Azithromax
  • Hep. lock IV to assess if PO intake adequate
  • Check sat- O2 d/c if under 92%
  • Encourage ambulation

consider discharge in approximately 2 days if continues to improve


Ambulatory Clinics

SOAP notes

Established patient

New patient

Lab orders

Xray orders


the note
The Note
  • Purpose of the visit: Mention at the top of the note why the patient has come to the clinic.
  • Medications: list all the medications in addition to listing the dosing strength and interval.
the note17
The Note
  • Issues/Events: Any new symptoms that the patient is experiencing (e.g. cough, low back pain, chest pain etc), which is described in the usual "HPI" format.

Specific concerns that the patient may have (e.g. patient initiated discussion about the role of cancer screening test, cholesterol measurement, etc).

the note18
The Note
  • Review of data/symptoms of disease states that the patient is known to have. Patients with diabetes, for example, will usually record their blood sugars.
  • Events: This includes any important clinical happenings that have occurred since our last visit. For example, trips to the emergency room
the outpatient note assessment
The Outpatient Note-Assessment
  • There are many ways of approaching clinical problems. You might find it helpful, particularly when dealing with complex clinical issues, to break each problem into its most basic elements, with a separate plan noted for each one.
differential diagnosis
Differential Diagnosis
  • V: vascular/visceral
  • I: infectious/inflammatory/immunologic
  • N: neurologic/nutritional/neoplastic
  • D: deficiency/degenerative
  • I: iatrogenic/intoxication/idiosyncratic
  • C: congenital/cardiac/circulatory
  • A: allergic/autoimmune/abuse
  • T: trauma/toxicity
  • E: endocrine/exposure
  • S: subluxation/somatic/structural/stress/secondary gain
  • A patient who presents with new dyspnea on exertion who also has known coronary artery disease, CHF, hypertension and hyperlipidemia.
  • Under a single "cardiovascular" heading, there is a good chance that the assessment and plan would become jumbled and confusing.
assessment 1
Assessment #1
  • Dyspnea on Exertion: Patient with mild decrease in exercise tolerance. No symptoms of angina. No exercise induced desaturation noted during observed 3 minute walk in clinic. no other suggestive symptoms. Etiology of dyspnea not clear. In any case, not obviously debilitated by symptoms.
plan 1
Plan #1
  • Obtain PFTs
  • Obtain CXR today
  • CBC to r/o anemia as cause
  • Re-Evaluate in clinic in 6 w (or patient will call sooner if symptoms worsen) at that time will consider repeat Exercise Tolerance Test to asses for ischemia/quantify exercise tolerance; also consider repeat echo to reassess LV function.
assessment 2
Assessment #2
  • Coronary Artery Disease: Known coronary disease. Patient continues to be active without symptoms.

Plan # 2:

  • Continue aspirin and lopressor (beta blocker)
  • Patient aware of symptoms suggestive of recurrent ischemia. If occur with activity, will repeat Exercise Tolerance Test.
assessment 3
Assessment #3
  • CHF: Known depressed left ventricular function on basis past MI, with EF 30% by last echo. No symptoms for over 1 year since initiation of medical treatment.

Plan #3:

  • Continue Lisinopril (ace-inhibitor) 40 mg/d
  • Continue lasix (diurectic) 40 mg/d
  • Check potassium, creatinine today
  • Repeat echo next year, unless symptoms/exam more clearly suggest worsening CHF
assessment 4
Assessment #4
  • Hypertension: Well controlled. End organ dysfunction (CHF and CAD) managed as above.

Plan #4:

  • Continue medical treatment as above
assessment 5
Assessment #5
  • Hyperlipidemia: LDL 80, HDL 40 both at target levels on Simvastatin (HMG-COA Reductase Inhibitor) 20 mg/d.

Plan #5:

  • Continue Simvastatin at current dose
  • Check liver enzymes (alt/ast), Creatinine Kinase today and in 6 months to assure no toxicity.
health care maintenance
Health Care Maintenance:
  • In a clinic, it's helpful to conclude each note with a Health Care Maintenance section.

For men this would include

  • Consideration for checking PSA (African-Americans beginning age over 40; Others over 50)
  • Colorectal cancer screening (age over 50 and every 5-10 years thereafter)
health care maintenance29
Health Care Maintenance:

For women:

  • Annual PAP smear (beginning at age of sexual activity)
  • Annual Mammography (beginning at age 40 or 50)
  • Colon Cancer Screening (with flex sig. or stool guaiac cards as above)
  • ? Bone Density Assessment (based on risk factors)
health care maintenance30
Health Care Maintenance:


  • Flu Vaccine (annually)
  • Pneumovax (age over 64 or those at risk)
  • Tetanus (every 10 years)
  • Pediatric patients have a schedule for vaccines from birth to 11 years of age

Neis Clinical Skills Lab, University of Kansas School of Medicine

  • USMLE® : Test Content & Practice Materials