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It’s Midnight. You’re on call at DRH You have 3 patients waiting in the modules…. How hard do you want to work for your information?. Appropriate Dictation Form and Content. Clifford A Kaye M.D. Summer Lecture Series 2006. Example #1 (page 1).

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it s midnight you re on call at drh you have 3 patients waiting in the modules
It’s Midnight.You’re on call at DRH You have 3 patients waiting in the modules…

How hard do you want to work for your information?

appropriate dictation form and content

Appropriate Dictation Form and Content

Clifford A Kaye M.D.

Summer Lecture Series 2006

example 1 page 1
Example #1(page 1)

DISCHARGE DIAGNOSIS: Congestive heart failure exacerbation.

PROCEDURES:

1. Paracentesis.

2. CT scan of the abdomen and pelvis.

3. 2D echo of the heart.

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: A 52-year-old African-American male with history of CHF who is HIV positive. He had a recent hospitalization at an outside institution. This hospitalization was for pneumonia. The patient did receive antibiotics at that time. The patient presents with a one week worsening of shortness of breath over his baseline shortness of breath. He also complains of cough productive of whitish sputum during that time. He has had fevers and chills. He has had orthopnea. He has had PND. The patient states that he has been compliant with all of his medications including antihypertensive medications. On the day of admission, the patient was sitting on the couch and had an episode of shortness of breath associated with some left-sided chest pain which was nonexertional and pleuritic in nature.

example 1 page 14
Example #1(page 1)

DISCHARGE DIAGNOSIS: Congestive heart failure exacerbation.

PROCEDURES:

1. Paracentesis.

2. CT scan of the abdomen and pelvis.

3. 2D echo of the heart.

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: A 52-year-old African-American male with history of CHF who is HIV positive. He had a recent hospitalization at an outside institution. This hospitalization was for pneumonia. The patient did receive antibiotics at that time. The patient presents with a one week worsening of shortness of breath over his baseline shortness of breath. He also complains of cough productive of whitish sputum during that time. He has had fevers and chills. He has had orthopnea. He has had PND. The patient states that he has been compliant with all of his medications including antihypertensive medications. On the day of admission, the patient was sitting on the couch and had an episode of shortness of breath associated with some left-sided chest pain which was nonexertional and pleuritic in nature.

example 1 page 2
Example #1(page 2)

PAST MEDICAL HISTORY: HIV for approximately 20 years. The last CD4 count is120. The patient is not taking any HAART therapy. Hypertension and CHF.

OUTPATIENT MEDICATIONS: Avelox, Zocor, Bactrim, and a diuretic.

ALLERGIES: HE IS NOT ALLERGIC TO ANY MEDICATIONS.

FAMILY HISTORY: Includes diabetes mellitus type 2 and hypertension. Also

myocardial infarction in the mother and father in their 60s.

SOCIAL HISTORY: Significant for cocaine use. Last use was within the last 3-5 days prior to admission. No IV drug use. No alcohol use. No smoking of tobacco. The patient lives alone in an apartment.

example 1 page 26
Example #1(page 2)

PAST MEDICAL HISTORY: HIV for approximately 20 years. The last CD4 count is 120. The patient is not taking any HAART therapy. Hypertension and CHF(Still not specific)

OUTPATIENT MEDICATIONS: Avelox, Zocor, Bactrim, and a diuretic.

ALLERGIES: HE IS NOT ALLERGIC TO ANY MEDICATIONS.

FAMILY HISTORY: Includes diabetes mellitus type 2 and hypertension. Also

myocardial infarction in the mother and father in their 60s.

SOCIAL HISTORY: Significant for cocaine use. Last use was within the last 3-5 days prior to admission. No IV drug use. No alcohol use. No smoking of tobacco. The patient lives alone in an apartment.

example 2
Example #2

CHIEF COMPLAINT: Altered Mental Status, per nursing home.

PRINCIPLE DIAGNOSIS: Delerium due to UTI.

DISCHARGE DIAGNOSES:

1. Multi-infarct Dementia

2. Hepatitis.

3. Diabetes type 2.

4. Incontinence.

5. Prostate cancer.

CONSULTS: Consults were to orthopaedic surgery, radiation oncology, psychiatry, occupational therapy, physical therapy, neurology, urology, and social work.

goals objectives
Goals & Objectives:

Teach the utility of discharge dictations as a means to communicate clear & concise clinical data.

  • What data to include and exclude.
  • How to organize the data.
  • When to dictate.
  • Who should dictate.
the data
Include:

Concise information.

Pertinent labs

Priceless Information:

Medication List

Follow-up Instructions

Psych/Cognitive Disorders

Baseline Exams

Exclude:

Repetition

Normal Labs

Prose

Inaccurate Information:

From the Patient

From the Chart

The Data
proper form the first page of a dictation
Proper FormThe First Page of a Dictation
  • Demographics
  • Date of Admission/Discharge
  • Primary Care Provider & Inpatient Attending
  • A Complete & Precise Problem List
    • Include what you discovered this admission
    • Include details (EF%, PAP, FEV1)
    • Obviates PMHx.
    • Obviates prose in HPI.
  • Chief Complaint & HPI
proper form the body of a dictation
Proper FormThe Body of a Dictation
  • Surgical History
  • Social History including contact persons and numbers
  • Pertinent Exam
    • Don’t bury pertinent findings in a lengthy normal exam.
  • Pertinent Studies
    • Labs
    • Gram Stains
    • Radiography
proper form the body of a dictation12
Proper FormThe Body of a Dictation

Hospital Course Organized by Problem

  • Digested Final Diagnosis

Briefly describe how the diagnosis was made/confirmed.

Refer to “pertinent studies” portion of the dictation for test results.

Briefly mention what was ruled out.

Suggestions for additional outpatient workup.

Do not detail how your team wandered down multiple paths looking for diagnoses.

proper form the body of a dictation13
Proper FormThe Body of a Dictation

Hospital Course Organized by Problem

  • Include details regarding baseline function

Exit ABGs if applicable.

Exit MMSE & Neurological Exams if applicable.

proper form the body of a dictation14
Proper FormThe Body of a Dictation

Final Diagnosis as a Symptom (the exception)

1.SOB, multifactorial:

A. Asthma exacerbation-

-Due to extensive and persistent tobacco use.

-Confirmed by CXR, ABG, and outpatient PFTs as detailed above.

-Symptoms improved with x,y,z interventions.

-Smoking Cessation counseling given.

-Follow-up & d/c meds listed below.

B. Exacerbation of Systolic CHF-

-ACS, acute infection, and thyroid abnormalities ruled out.

-Suspected due to medical and dietary non-compliance.

N.B. The Problem List above will detail the etiology and anatomy of the patient’s CHF.

improper form
Improper Form
  • Repetition
  • Misleading Information
  • Unnecessary Information
repetition
DATE OF ADMISSION: 10/06/2005

DATE OF DISCHARGE: 10/09/2005

ADMITTING DIAGNOSES:

1. Abscess with methicillin-resistant Staphylococcus aureus.

2. Urinary tract infection due to methicillin-resistant Staphylococcus aureus.

3. Central respiratory failure due to brainstem radiotherapy.

4. Anemia.

5. Fever, leukocytosis.

6. Syndrome of inappropriate antidiuretic hormone.

7. Neurofibromatosis.

8. Sepsis.

DISCHARGE DIAGNOSIS:

Central respiratory failure

Pneumonia, methicillin-resistant Staphylococcus aureus sepsis.

__________ collapse.

Anemia.

#1

Repetition
repetition17
HISTORY OF PRESENT ILLNESS: The patient is transferred from another Children's Hospital in Detroit for ventilation settings and infection control. The patient is a 30-year-old Caucasian male with past medical history of congenital neurofibromatosis, SIADH, and posterior [fossa] astrocytoma with radiotherapy in August 2005. He had multiple shunt revisions for hydrocephalus; last shunt put in March 07, 2005. He had hemorrhagic stroke on March 02, 2005, the day after the shunt revision and had been in rehabilitation since April. He did tolerate it progressively. He could not walk, eat, and he had difficulty in swallowing both liquids and solids, and collapsed at home on August 07, 2005, and brought to Harper Hospital. He was ventilated due to central respiratory failure thought to be secondary to brainstem radiation therapy and tracheostomy tube was put in August 30, 2005. He was found to have pneumonia. On September 19, 2005, he had a fever spike and a blood and sputum,urine cultures revealed vancomycin resistant Enterococcal urinary tract infection. Chest x-ray showed a resolving pneumonia, and final cultures also grew MRSA tracheal bronchitis.

#2

Repetition
repetition18
After completion of antibiotic on September 23, 2005, he had another fever spike and was started on empiric Zosyn and tobramycin. Basically, he was admitted for infection control, his sepsis, and for ventilation settings. He was discharged from Children's Hospital in Detroit with Zosyn, tobramycin, phenobarbital, labetalol, subcutaneous heparin and multivitamins.

PAST MEDICAL HISTORY: Congenital neurofibromatosis diagnosed at six weeks of age, amputation of left leg at seven years old. At age 13, he had radiotherapy for bilateral optic tumors. In 1987, he had removal of posterior [fossa] astrocytoma and one week later first cerebrospinal fluid shunt was put. Between 1987 and 1996, he had six shunt revisions. Between January 2005, and March 2005, he had another six more shunt revisions. He has a history of grand mal seizures. In March 2005, he had hemorrhagic stroke. In August 2005, on MRI it was found that he had another brainstem tumor and he completed ten days of radiotherapy. A PIC line was placed two weeks ago at another Children's Hospital and feeding tube was placed one month ago after two weeks of nasogastric tube feeding.

FAMILY HISTORY: History of neurofibromatosis in the mother.

PAST SURGICAL HISTORY: As stated above.

#3

Repetition
repetition19
EMERGENCY DEPARTMENT COURSE: When he came to the emergency room, his ventilation settings were FIO2 40%, respiratory rate 14, tidal volume 450. Peak flow 70, PEEP 5, inspiration and expiration ratio was 1/4.9. Heart rate was 124, blood pressure was 117/70, oxygen saturation was 100%.

GENERAL EXAM (Omitted)

LABORATORY DATA: On admission, sodium 132, potassium 3.3, chloride 87, bicarb 38, BUN 26, creatinine 0.3, glucose 81. White blood cell count 12.5, hemoglobin 7.6, hematocrit 23.7, platelets 248, calcium 11, magnesium 1.9, phosphatase 1.6, troponin less than 0.02. Arterial blood gas showed pH 7.65, pCO2 37.7, pO2 121, bicarbonate 33.6. Bands 1.5%. Urinalysis showed urine protein 2+, red blood cells less than 2, white blood cell count less than 5, bacteria 2+.

****

Repetition
repetition20
HOSPITAL COURSE: The patient is a 30-year-old Caucasian male with a past medical history of congenital neurofibromatosis. He was transferred from one of the Children's Hospital in Detroit with a diagnosis of sepsis with methicillin-resistant Staphylococcus aureus as well as anemia and for adjustment of his ventilation settings.

1. Infectious disease. At another Children's Hospital, he had a history of vancomycin resistant urinary tract infection and methicillin-resistant Staphylococcus aureus tracheal bronchitis and pneumonia. So we started him on __________ 500 mg intravenous every twelve hours and cefepime, tobramycin for possible hospital acquired pneumonia.

We consulted ID and Neurosurgery for a possible shunt infection….. ID was consulted and they recommended to start Flagyl as well. Blood cultures continued to grow out… gram positive cocci in clusters in aerobic bottle. An echo was done to rule out endocarditis and it was negative. Ejection fraction was 60%.

Since the blood cultures showed gram positive cocci, we started him on

vancomycin later and we had a CT scan of the head that showed sinusitis

bilaterally, so we started him on moxifloxacin and consulted ENT for sinusitis

management. They removed the PIC line.

#4

Repetition
repetition21
HOSPITAL COURSE: (cont)

So, on day four of admission, he was on moxifloxacin 400 mg once a day, vancomycin 500 mg intravenous piggyback every twelve hours, Flagyl 500 mg every eight hours, and cefepime.

1. Respiratory failure most likely central apnea secondary to brain stem radiotherapy. We kept the ventilation settings at a respiratory rate of 12 to increase the CO2, because when he was admitted he had metabolic alkalosis, with bicarbonate 34, and pCO2 37. We kept FIO2 40%.

2. Chest x-ray showed collapse of right upper lung, and we started chest physiotherapy by frequent suctioning of tracheostomy,due to possible mucous block.

3. He has a history of syndrome of inappropriate antidiuretic hormone and he came with hyponatremia. We started intravenous fluids of normal saline 100 cc every hour and watched his urine output. Until day #3 of admission, his urine output was okay; more than 60 cc per hour, but later on he started having decreased urine output …

Repetition
repetition22
HOSPITAL COURSE: (cont)

He had anemia… We watched the hemoglobin and hematocrit daily and he was on intravenous Protonix 40 mg every twelve hours. It was most likely chronic disease[…]

He was on gastrointestinal and deep venous thrombosis prophylaxis of intravenous Protonix and subcutaneous heparin.

Nutrition. We started him on Jevity feedings.

On October 09,. 2005, the Pediatric Neurosurgery was consulted and they were taking care of the patient actually. They came and explained the bad prognosis of the patient to the family and they recommended terminal weaning. The family accepted that. The patient's family decided on terminal wean of around 11:00 p.m. on October 09, 2005. The patient was off the ventilator and at 11:27 p.m., the patient went into cardiorespiratory arrest and expired. The patient was declared dead around 11:30 p.m., his pupils were fixed...

Repetition
misleading information
MisleadingInformation

Diagnosis: Post Obstructive Right Upper lobe Pneumonia

Prognosis: Fair

History of Presenting Complaint:

Patient is a 56 year old Caucasian male, without any significant past medical history who presented to the VADET Urgent care on 09/19/05 with complaints of chest pain and cough.The patient states that he was doing well health wise until about three months ago when he started losing weight. He has lost a total of 25 pounds in 3 months. He also has a constant deep seated chest pain on the right side of the upper chest that increases when he takes a deep breath.

Past Medical:-Patient denies any known previous illnesses.

Social History: Married but currently separated. Lives with a friend. Currently unemployed. Tobacco-80 pack-year history i.e 2 packs/day for 40 years-Quit 2 months ago Alcohol- About 3-4 half pints of hard liqor/day on and off for about 20 years. He says he also quit drinking about 2 months ago.

misleading information24
Misleading Information

Hospital course:

1-Respiratory:

Right Upper lung infiltrate-questionable mass- per imaging studies- Chest X-ray and CT thorax were not conclusive.Tuberculosis was ruled out with three negative AFB smears in sputum. The AFB smear in the bronchial aspirate was also negative. Culture results are pending. The patient had a bronchoscopy with lavage and biopsies done: -Results of biopsy/Bronchial lavage: Culture of Bronchial wash grew a few viridans streptococci. Negative for malignancy. Acute inflammatory cells and bronchial epithelium with minimal atypia, consistent with reactive changes. Special stain for fungus is negative. Right bronchial lavage: Negative for malignancy. Mainly acute inflammatory cells. Right upper lobe biopsy: Fragments of bronchial mucosa with acute and chronic inflammation, congestion, reactive epithelial changes,, focal anthracosis and hyalinization and blood clot. No lung parenchyma is included in the biopsy. In order to rule out a primary malignancy in some other site, an abdominal and pelvic CT scan was done-The results of the CT of abdomen were reviewed with the radiologist and there is no evidence of malignancy in any intraabdominal organ. A whole body bone scan did not show any metastatic lesions. The patient was treated with Levofloxacin 750mg Q day for a total of 14 days per ID recommendation.

misleading information25
Misleading Information

Hospital course:

1-Respiratory:

Right Upper lung infiltrate-questionable mass- per imaging studies- Chest X-ray and CT thorax were not conclusive.Tuberculosis was ruled out with three negative AFB smears in sputum. The AFB smear in the bronchial aspirate was also negative. Culture results are pending. The patient had a bronchoscopy with lavage and biopsies done: -Results of biopsy/Bronchial lavage: Culture of Bronchial wash grew a few viridans streptococci. Negative for malignancy. Acute inflammatory cells and bronchial epithelium with minimal atypia, consistent with reactive changes. Special stain for fungus is negative. Right bronchial lavage: Negative for malignancy. Mainly acute inflammatory cells. Right upper lobe biopsy: Fragments of bronchial mucosa with acute and chronic inflammation, congestion, reactive epithelial changes,, focal anthracosis and hyalinization and blood clot. No lung parenchyma is included in the biopsy. In order to rule out a primary malignancy in some other site, an abdominal and pelvic CT scan was done-The results of the CT of abdomen were reviewed with the radiologist and there is no evidence of malignancy in any intraabdominal organ. A whole body bone scan did not show any metastatic lesions. The patient was treated with Levofloxacin 750mg Q day for a total of 14 days per ID recommendation.

FOB

Results

misleading information26
Misleading Information

Hospital course:

2-The patient came in with an elevated WBC-16.9 with neutrophilia and thrombocytosis-probably reactive thrombocytosis: WBC on discharge was 11.5 . Platelet count 991. Afebrile .Discharged on levofloxacin.

3.Patient was discharged with a diagnosis of post obstructive pneumonia and will follow up for further investigation on out-patient basis. He might need repeat bronchoscopy to rule out malignancy or other cause for the right upper lung infiltrate and weigthloss. The patient was discharged in stable condition.

unnecessary information
Unnecessary Information

PAST MEDICAL HISTORY: His past medical history was significant for traumatic brain injury in 2002 secondary to gunshot wound and seizure disorder. The patient states that he cleans his ears with Q-tips and frequently has wax building up. He also states that he had ear pain for 1 week without any discharge. No fever, nausea, vomiting, chills or abdominal pain. No change in urine or bowel movements. He uses a cane to walk. He denies seizures for the past year. On September 23, the patient was transferred to medicine A and was accepted by us and the following history was obtained from his mother which is the legal guardian of the patient given the poor history giver the patient was at that time. Apparently, 12 days before this date, September 23, the patient was doing fine. His mother noticed one black spot on his eye. He started to self-medicate with No More Tears. The next day, as per his mother, he had an absent seizure, and when he went to see the doctor he was found to have thrush, which was successfully treated with Nystatin. He was given another eye drop of which the mother does not

prose29
Prose

FINAL DIAGNOSIS: New onset diabetes mellitus.

SECONDARY DIAGNOSES:

1. Hypertension.

2. Hypertriglyceridemia.

CHIEF COMPLAINT: This patient was admitted with the chief complaint of drinking a lot, draining a lot, and blurring vision.

HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old man with a past medical history of hypertension and chronic back pain who presented to the emergency department complaining of two months of polyuria, polyphagia, polydipsia, nocturia, blurring vision. The patient states that he has many family members with diabetes and recognized these symptoms he was having as being caused by ….

prose30
Prose

HOSPITAL COURSE: Diabetes. The patient's glucose was controlled with intravenous insulin in the emergency department. While in the emergency department, his glucose came down to 472. The patient was admitted to the floor and started on a 2000 calorie ADA diet with Accu-Cheks every two hours times three and then every four hours afterwards. He was started on two antihyperglycemics: Glipizide 5 mg by mouth twice daily and Avandia 4 mg by mouth daily, and insulin sliding scale coverage. He was also given normal saline at 125 cc per hour, which was changed to D5 0.5% normal saline at 125 cc per hour when his Accu-Chek was less than 250. We rechecked the electrolytes several times throughout the night and the next day to make sure that he was not developing acidosis. A fasting lipid profile was done which showed an elevated triglyceride of 1755 and a cholesterol of 218, HDL was 17, LDL was not able to be calculated because of the increased triglycerides.

prose31
Prose

HOSPITAL COURSE: Diabetes. The patient's glucose was controlled with intravenous insulin in the emergency department. While in the emergency department, his glucose came down to 472. The patient was admitted to the floor and started on a 2000 calorie ADA diet with Accu-Cheks every two hours times three and then every four hours afterwards. He was started on two antihyperglycemics: Glipizide 5 mgby mouth twice daily and Avandia 4 mg by mouth daily, and insulin sliding scale coverage. He was also given normal saline at 125 cc per hour, which was changed to D5 0.5% normal saline at 125 cc per hour when his Accu-Chek was less than 250. We rechecked the electrolytes several times throughout the night and the next day to make sure that he was not developing acidosis. A fasting lipid profile was done which showed an elevated triglyceride of 1755 and a cholesterol of 218, HDL was 17, LDL was not able to be calculated because of the increased triglycerides.

prose32
Prose

HOSPITAL COURSE (continued): Hemoglobin A1C was ordered, but is pending at the time of discharge. The patient was provided with diabetic teaching. Because he has so many family members who are diabetics, he understands the diet and lifestyle that is required. He is prepared to check his glucose at home twice a day and record this and to bring this with him to his follow up office visit. Because the patient does not have insurance, social work was consulted. The patient was switched from Avandia to Glucophage 500 mg by mouth twice daily, because of the expense of Avandia. The patient currently has no complaints. The polyuria, polydipsia and polyphagia has decreased. He no longer has blurry vision. His most recent Accu-Chek was 273. The patient has been scheduled in my clinic in the GMAP Building for 1p.m. on Monday, 08/22/2005.

prose33
Prose

HOSPITAL COURSE (continued): Hemoglobin A1C was ordered, but is pending at the time of discharge. The patient was provided with diabetic teaching. Because he has so many family members who are diabetics, he understands the diet and lifestyle that is required. He is prepared to check his glucose at home twice a day and record this and to bring this with him to his follow up office visit. Because the patient does not have insurance, social work was consulted. The patient was switched from Avandia to Glucophage 500 mg by mouth twice daily, because of the expense of Avandia. The patient currently has no complaints. The polyuria, polydipsia and polyphagia has decreased. He no longer has blurry vision. His most recent Accu-Chek was 273. The patient has been scheduled in my clinic in the GMAP Building for 1p.m. on Monday, 08/22/2005.

proper form
Proper Form
  • Abnormal Labs Only
  • Priceless Information Regarding
    • Cognitive Disorders
    • Personality Disorders
    • Baseline Function
    • Social History
  • DIGESTION of your workup
pertinent labs
Pertinent Labs

DATE OF ADMISSION: 10/27/2005

DATE OF DISCHARGE: 10/31/2005

FINAL DIAGNOSIS: Acute lobar nephronia/ early renal abscess.

HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old African-American female with no significant past medical history…..

FAMILY HISTORY: The patient's father had cancer, unknown type.

SOCIAL HISTORY: ….

PHYSICAL EXAMINATION: ….

LABORATORY DATA: White count 16.1, hemoglobin 9.4. The patient had a normal chem-7. Amylase was normal at 50. Pregnancy test was negative. Liver function tests were normal. Urine drug screen was negative. UA was positive for 2+ bacteria, trace leukocyte esterase, positive nitrites, 5 to 10 WBCs.

priceless information cognitive disorders
Priceless InformationCognitive Disorders

PHYSICAL EXAMINATION: VITALS: Blood pressure 152/100, heart rate 83, respiratory rate 16, temperature 97.8. GENERAL: He is an elderly African- American gentleman, in restraints when seen. He appears confused but in no acute distress. CARDIOVASCULAR: Positive for a pacemaker in the right upper chest, otherwise within normal limits. LUNGS: Within normal limits. NECK: Within normal limits. ABDOMEN: Basically normal. Bowel sounds positive. No tenderness or distention. No rebound tenderness. No CVA tenderness. RECTAL: Tone normal. Temperature normal. The prostate had an irregular surface. The rectum was full of hard stool, but there was no blood, no secretions, no signs of hemorrhoids and no pain. No perianal lesions or ulcerations. NEUROLOGIC:The patient was alert, but he was only oriented x1. He was oriented only to place. No Babinski or meningeal signs. Strength and sensation was intact. Cranial nerves II through XII were grossly intact.

LABORATORY DATA: Within normal limits. A CT scan of the head showed no signs or evidence of stroke.

HOSPITAL COURSE: Dementia. A CT scan was negative. His electrolytes basically were within normal limits. TSH was normal. B12 and folate was normal. Albumin and calcium was normal.

priceless information cognitive disorders37
Priceless InformationCognitive Disorders

PHYSICAL EXAMINATION: VITALS: Blood pressure 152/100, heart rate 83, respiratory rate 16, temperature 97.8. GENERAL: He is an elderly African- American gentleman, in restraints when seen. He appears confused but in no acute distress. CARDIOVASCULAR: Positive for a pacemaker in the right upper chest, otherwise within normal limits. LUNGS: Within normal limits. NECK: Within normal limits. ABDOMEN: Basically normal. Bowel sounds positive. No tenderness or distention. No rebound tenderness. No CVA tenderness. RECTAL: Tone normal. Temperature normal. The prostate had an irregular surface. The rectum was full of hard stool, but there was no blood, no secretions, no signs of hemorrhoids and no pain. No perianal lesions or ulcerations. NEUROLOGIC:The patient was alert, but he was only oriented x1. He was oriented only to place. No Babinski or meningeal signs. Strength and sensation was intact. Cranial nerves II through XII were grossly intact. (MMSE)

LABORATORY DATA: Within normal limits. A CT scan of the head showed no signs or evidence of stroke.

HOSPITAL COURSE: Dementia. A CT scan was negative. His electrolytes basically were within normal limits. TSH was normal. B12 and folate was normal. Albumin and calcium was normal.

priceless information social history page 1
Priceless InformationSocial HistoryPage 1

DATE OF ADMISSION: 09/13/2005

DATE OF DISCHARGE: 09/16/2005

PRIMARY DIAGNOSIS: Congestive heart failure exacerbation secondary to pneumonia.

SECONDARY DIAGNOSES:

1. Hypertension.

2. Congestive heart failure.

3. Hepatitis C.

The only procedure performed on the patient was an echocardiogram.

PROBLEM LIST:

1. Pneumonia.

2. Congestive heart failure.

priceless information social history page 2
Priceless InformationSocial HistoryPage 2

HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old African-American male with a past medical history of CHF, hypertension and hepatitis C. The patient is often medically noncompliant and has multiple hospital admissions. Last night the patient became short of breath, coughing at night, could not eat, and decided to prophylactically come to visit the hospital. No fevers, no chills, no night sweats, no weight loss. No chest pain, no abdominal pain, no diarrhea, no constipation. No leg pain. The patient can walk at baseline half a block and the patient can walk up four individual stairs. The patient sleeps on five pillows. He does have orthopnea, PND twice a night; recently that increased to four times a night. The patient denies any sick contacts or temperatures at home.

MEDICATIONS: At home, the patient takes Lopressor 50 mg p.o. b.i.d., Lisinopril 10 mg p.o. q.day, Lasix 40 mg p.o. q.day, aspirin 325 mg p.o. q.day, albuterol 2.5 mg nebulizer q.4h. as needed for shortness of breath, Atrovent 0.5 mg nebulizer q.4h. p.r.n.

PAST MEDICAL HISTORY: CHF for five years. Hypertension and hepatitis C. Substance abuse.

priceless information social history page 3
Priceless InformationSocial HistoryPage 3

ALLERGIES: NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY: The patient is not aware of his family history as they all live in New York.

SOCIAL HISTORY: The patient lives with his girlfriend and children. The patient is unemployed. A 20 pack per day smoking history. Does have some alcohol use, recent tobacco use and cocaine use. Last cocaine use was three days prior to admission.

priceless information digestion of your workup
Priceless InformationDigestion of Your Workup

DISCHARGE DIAGNOSES:

1. Syncope,possibly due to volume depletion.

2. Hypertension.

CONSULTATIONS:

1. Cardiology.

2. Neurology.

HISTORY OF PRESENT ILLNESS: This is an 80-year-old African American female who presented with fainting and falling down to the ground. Apparently she did fall this morning. She suddenly fell down and EMS brought her to the hospital.

She has lost consciousness and she is not aware of any preceding symptoms. She had no seizure, no chest pain, no palpitations, denies dizziness, no loss of bowel or bladder control, no visual change and no weakness in her limbs. There was no confusion after the episode.

priceless information digestion of your workup42
Priceless InformationDigestion of Your Workup

PAST MEDICAL HISTORY:

1. Hypertension for 15 years.

2. No diabetes noted in the past.

3. No history of heart disease.

4. No history of CVA.

5. No previous history of seizure.

MEDICATIONS:

1. Nifedipine 30 mg orally every day.

2. Librium as needed.

FAMILY HISTORY: She is not aware of any illnesses of family.

SOCIAL HISTORY: She smokes a half a pack per day since teenager, denies alcohol and intravenous drugs. Home Situation?

PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 139/18 erect and 149/18 supine. Pulse 89 erect and 80 supine. Temperature 98.1. Respirations 20.

priceless information digestion of your workup43
Priceless InformationDigestion of Your Workup

GENERAL: She is an 80-year-old elderly female. She is not in any distress. HEENT: Extraocular movements are intact, anicteric sclerae. Neck soft. There is no JVD. She had ecchymosis on the face and swollen lips. HEART: Regular rate and rhythm, S1, S2 were heard, no murmur or gallop. LUNGS: Clear to auscultation bilaterally. No palpable lymph nodes. ABDOMEN: Soft, nontender, no distention, positive bowel sounds. EXTREMITIES: No pedal edema. NEUROLOGICAL: Alert, oriented x3, no focal neurologic deficit???

EKG shows normal sinus rhythm, left ventricular hypertrophy by voltage criteria.

Chest x-ray showed chronic mild pulmonary disease.

CT of the head showed no acute intracerebral hemorrhage, midline shift or mass effect. It did show chronic microvascular ischemic changes and old lacunar infarcts.

priceless information digestion of your workup44
Priceless InformationDigestion of Your Workup

HOSPITAL COURSE: She was admitted for syncope.Cardiology and neurology were consulted and cardiology suggested that syncope not related to any cardiovascular problem. A 2-D echo was performed and it showed ejection fraction of 65%, normal left ventricular function and no abnormal finding. Her serial EKGs showed normal sinus rhythm. Troponin was negative three times. Neurology service suggested that syncope was not related to any neurogenic problem. The patient received gentle IV hydration. She was stabilized and discharged on July 18, 2005 with her home medications, Nifedipine for her blood pressure 30 mg orally every day.

The patient was instructed to return to her outpatient clinic follow up and instructions plus diet was given.

CONDITION ON DISCHARGE: The patient was discharged in stable condition.

priceless information digestion of your workup45
Priceless InformationDigestion of Your Workup

DIGEST HERE

HOSPITAL COURSE: She was admitted for syncope.Cardiology and neurology were consulted and cardiology suggested that syncope not related to any cardiovascular problem. A 2-D echo was performed and it showed ejection fraction of 65%, normal left ventricular function and no abnormal finding. Her serial EKGs showed normal sinus rhythm. Troponin was negative three times. Neurology service suggested that syncope was not related to any neurogenic problem. The patient received gentle IV hydration. She was stabilized and discharged on July 18, 2005 with her home medications, Nifedipine for her blood pressure 30 mg orally every day.

The patient was instructed to return to her outpatient clinic follow up and instructions plus diet was given.

CONDITION ON DISCHARGE: The patient was discharged in stable condition.

Or you’re asking the next team to do that work.

precision
Precision

DATE OF ADMISSION: 07/07/2005

DATE OF DISCHARGE: 07/08/2005

ATTENDING PHYSICIAN: RANDY A LIEBERMAN, MD

DIAGNOSES: 1. Chronic heart failure.

2. Hypertension.

PROCEDURES: ICD generator change.

HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old African-American male with a history of pulseless ventricular fibrillation, ICD placement in 1986, And he was admitted for a generator change at this time. The patient denies any syncope, chest pain, shortness of breath or palpitations. He has no complaints at the present time.

ALLERGIES: No known drug allergies.

PAST SURGICAL HISTORY: Colectomy because of colon cancer

precision47
Precision

SOCIAL HISTORY: The patient quit smoking in 2005.

ASSESSMENT: The patient was admitted to the EP department. At the time of

admission he had no complaints.

PHYSICAL EXAMINATION: The patient was in no acute distress. Cardiovascular: Clear heart tones. Regular rhythm. Extremities: No edema. Lungs: Breathing is audible bilaterally. Neuro: The patient is alert and oriented x3. No focal deficits.

HOSPITAL COURSE: The procedure was performed on July 7 at 5:30 p.m. The ICD generator was changed without any complications. Blood loss was less than 50 cubic cm. Local anesthesia and IV sedation was given. He was admitted to the floor, CCU, on July 7, 2005 at 9:15 p.m. The patient was in stable condition. He denied any chest pain, shortness of breath or palpitations. He had no fever. No hematoma formation at the ICD placement site. His hospital course was stable.

precision48
Precision

His medications include Tylenol No. 3 one to two pills p.o. q.4h. for pain control, morphine 1 to 2 mg IV push q.2h. for pain control, Coreg 25 mg p.o. b.i.d., lisinopril 40 mg p.o. daily, Norvasc 10 mg p.o. daily, Lasix 40 mg p.o. daily, Zocor 20 mg p.o. daily.

A lab test the next morning, July 8, showed a sodium of 139, potassium 3.7, chloride 108, bicarbonate 26, BUN 11, creatinine 0.9, glucose 75. White count 9.7, hemoglobin 129, hematocrit 39.1, platelets 210. There was a small hematoma formation at the ICD placement site. This was followed by the EP technician.

DISPOSITION: The patient was discharged home on July 8, 2005 with follow up with Dr. Randy Lieberman in the EP Clinic. The appointment is scheduled for July 22, 2005 at 8:30 a.m. The phone number for contact is 313-745-2626.

CONDITION ON DISCHARGE: Stable to home.

precision49
Precision

.

This dictation was concise but not THOROUGH

Review of the medical record revealed:

  • CASHD with 40% mid LAD 100% distal LAD with patent grafts
  • An akinetic inferior wall
  • EF 10% without LVH
  • h/o Atrial Fibrillation
  • PUD
  • What were his discharge medications??
proper organization complete precise data on the first page
Proper OrganizationComplete & Precise Data on the First Page

CHIEF COMPLAINT: Altered Mental Status, per nursing home.

PRINCIPLE DIAGNOSIS: Delerium due to UTI.

DISCHARGE DIAGNOSES:

1. Multi-infarct Dementia

2. Hepatitis.

3. Diabetes type 2.

4. Incontinence.

5. Prostate cancer.

CONSULTS: Consults were to orthopaedic surgery, radiation oncology, psychiatry, occupational therapy, physical therapy, neurology, urology, and social work.

improper organization incomplete data on the first page
Improper OrganizationIncompleteData on the First Page

DATE OF ADMISSION: 08/11/2005

DATE OF DISCHARGE: 08/14/2005

PRIMARY DIAGNOSIS: Congestive heart failure.

SECONDARY DIAGNOSES:

1. Hypertension.

2. Status post mitral valve replacement.

PROCEDURE: Esophagogastroduodenoscopy?

CHIEF COMPLAINT: Upper abdominal distention and pain since 1 month.

HISTORY OF PRESENT ILLNESS: This is a 55-year-old African-American female who presented with upper abdominal squeezing-type of pain and progressive abdominal distention since about a month. The patient stated that she has been feeling sick for about 3 years, but symptoms got worse in the past 1 month. She also complained of shortness of breath….

improper organization problem list scattered throughout text
Improper Organization:Problem List Scattered Throughout Text

PAST MEDICAL HISTORY: Hypertension, CHF, ARF, anemia, pancreatitis, alcohol abuse, arthritis.

PAST SURGICAL HISTORY: Mitral valve replacement (porcine), motor vehicle accident with loss of consciousness in 2001

SOCIAL HISTORY: Unemployed, lives alone. Her son helps her out. She quit smoking and drinking 3 weeks ago. She smoked a half a pack a day for about 36 years. She denied any drug use. She has Medicaid insurance.

DIAGNOSTIC STUDIES:

--Echocardiogram in March 2005, showed an ejection fraction of 45%, normal LV size with mild LV hypertrophy and a bioprosthetic valve.

--CT of the abdomen showed free pelvic fluid, moderate with pleural

effusion and no bowel obstruction.

improper form symptom listed as diagnosis
Improper FormSymptom Listed as Diagnosis

HOSPITAL COURSE: The patient was admitted with the following problems:

PROBLEM NUMBER 1. Congestive heart failure exacerbation….

PROBLEM NUMBER 2. Abdominal pain. One of the main complaints that the patient came in with was abdominal pain, and the first impression was due to liver congestion secondary to CHF. The patient showed some improvement on the first couple of days after admission, but again, she started to complain of abdominal pain. Then, surgery was consulted, and after surgery saw her, they decided that the problem was not a surgical problem. Finally, endoscopy was done, and endoscopy showed diffuse gastritis and a little bit deformed bulb, and she was ordered a proton pump inhibitors. Endoscopy was ordered after GI was consulted. Ultrasound of the gallbladder: no stones in the gallbladder, but it showed diffuse fatty infiltration of the liver 2 right-sided pleural effusions.

improper form diagnosis hidden in text
Improper FormDiagnosis Hidden in Text

HOSPITAL COURSE: The patient was admitted with the following problems:

PROBLEM NUMBER 1. Congestive heart failure exacerbation….

PROBLEM NUMBER 2. Abdominal pain. One of the main complaints that the patient came in with was abdominal pain, and the first impression was due to liver congestion secondary to CHF. The patient showed some improvement on the first couple of days after admission, but again, she started to complain of abdominal pain. Then, surgery was consulted, and after surgery saw her, they decided that the problem was not a surgical problem. Finally, endoscopy was done, and endoscopy showed diffuse gastritis and a little bit deformed bulb, and she was ordered a proton pump inhibitors. Endoscopy was ordered after GI was consulted. Ultrasound of the gallbladder: no stones in the gallbladder, but it showed diffuse fatty infiltration of the liver 2 right-sided pleural effusions.

the data55
Include:

Concise information.

Pertinent labs

Priceless Information:

Medication List

Follow-up Instructions

Psych/Cognitive Disorders

Baseline Exams

Exclude:

Repetition

Normal Labs

Prose

Inaccurate Information:

From the Patient

From the Chart

The Data
slide56
“If you don’t know your destination …

… every road will take you there”

the destination
The Destination

Organize yourself

  • Index Card with static information
    • Name
    • Numbered Problem List
      • Cognitive Deficits
      • Psychiatric Diagnoses
      • Pertinent Social History
    • Family Contacts
    • Medications
    • PCP Name & Number
proper form the first page of a dictation58
Proper FormThe First Page of a Dictation
  • Demographics
  • Date of Admission/Discharge
  • Primary Care Provider
  • A Complete & Precise Problem List
    • Include what you discovered this admission.
    • Include details (EF%, PAP, FEV1)
    • Obviates PMHx.
    • Obviates prose in HPI.
  • Chief Complaint & HPI
proper form the body of a dictation59
Proper FormThe Body of a Dictation
  • Family & Surgical Histories
  • Social History including contact persons and numbers
  • Pertinent Exam
    • Don’t drown pertinent findings in a normal exam.
  • Pertinent Studies
    • Labs
    • Gram Stains
    • Radiography
proper form the body of a dictation60
Proper FormThe Body of a Dictation

Hospital Course Organized by Problem

  • Digested Final Diagnosis

Briefly describe how the diagnosis was made/confirmed.

Refer to “pertinent studies” portion of the dictation for test results.

Suggestions for additional outpatient workup.

Lastly, briefly mention what was ruled out.

Do not detail how your team wandered down multiple paths looking for diagnoses.

  • Include details regarding baseline function

Exit ABGs if applicable.

Exit MMSE & Neurological Exams if applicable.

proper form the body of a dictation61
Proper FormThe Body of a Dictation

Final Diagnosis as a Symptom (the exception)

1.SOB, multifactorial:

A. COPD exacerbation-

-Due to extensive and persistent tobacco use.

-Confirmed by CXR, ABG, and outpatient PFTs as detailed above.

-Symptoms improved with x,y,z interventions.

-Smoking Cessation counseling given.

-Follow-up & d/c meds listed below.

B. Exacerbation of Systolic CHF-

-ACS, acute infection, and thyroid abnormalities ruled out.

-Suspected due to medical and dietary non-compliance.

N.B. The Problem List above will detail the etiology and anatomy of the patient’s CHF.

proper form the body of a dictation62
Proper FormThe Body of a Dictation

Final Diagnosis as a Symptom (the exception)

1.SOB, multifactorial:

A. Asthma exacerbation-

-Due to extensive and persistent tobacco use.

-Confirmed by CXR, ABG, and outpatient PFTs as detailed above.

-Symptoms improved with x,y,z interventions.

-Smoking Cessation counseling given.

-Follow-up & d/c meds listed below.

B. Exacerbation of Systolic CHF-

-ACS, acute infection, and thyroid abnormalities ruled out.

-Suspected due to medical and dietary non-compliance.

N.B. The Problem List above will detail the etiology and anatomy of the patient’s CHF.

proper form the conclusion
Proper FormThe Conclusion
  • Condition at Discharge
  • Discharge Medication List
    • Come January 1 2006, all organizations must be reconciling each list of recently taken medications against the initial set of orders at the new site, and Follow-up Appointment List
  • Discharge Instruction
    • Diet
    • Activity
  • Follow-up Appointments
jcaho national patient safety goal 8
JCAHO National Patient Safety Goal 8

"Accurately and completely reconcile medications across the continuum of care“

  • Goal: Reduce Adverse Drug Events
  • Compile the admission medication list and comparing those medications with what is being prescribed.
  • The DMC will communicate a complete medication list to whoever is the next health care provider in charge.
when to dictate
When to Dictate

The same day the patient is:

Discharged Home

Leaves AMA

Leaves your service after 7 days

ICU transfers

Off service

Discharged to another facility

RIM

NH

Another DMC Hospital

who should dictate
Who Should Dictate?

A physician who knows the patient’s hospital course