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Written Documentation
Part I
Steven Rougas, MD MS.MEd 14
Doctoring Year 2September 5, 2013
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Goals
What is a Medical Record? What are the basics ofWritten Documentation?
How do I write a full History and Physical? How do I write a progress note (SOAP)? Practice a complete written history and physical Review expectations of case write-ups in Doctoring
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Logistics
1. Medical Record (5 min) 2. Written Documentation (10 min) 3. History and Physical (25 min)
4. SOAP Notes (5 min)
5. Doctoring Write-ups (5 min)3
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DISCLOSURES
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THE MEDICAL RECORD
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Written Documentation Skills
Required reading with overview, template, and sample H&Ps.
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The Medical Record
Medical Record Case Write-Up
Legal document Ownership Not written = not done Written but not done
= FRAUD
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The Medical Record
Purpose Patient Care Delivery Manage Risk Billing &
Reimbursement
Education Regulation Research
Content Identification Info Health History Medical Exam
Findings
Test Results Medications/Rx Referrals Problem List
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WRITTEN DOCUMENTATION
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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report
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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report
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Written Documentation
Demographics Patient Name or
Identifier ** Date / Time / Writer Source / Reliability
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Subjective
What the patient tells you
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Written Documentation
Subjective (S) CC HPI PMH SH FH ROS
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Written Documentation
Chief Complaint (CC)I cant stop coughing
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Written Documentation
History of Present Illness (HPI) JS is a 34 year old female with no significant PMH who presents
with 1 week of a productive cough. The patient recently traveled
to Costa Rica with friends and noticed the cough. No one else iscurrently sick. She states the cough is intermittent throughout theday, worse at night. Nothing makes it better, but exerting herselfmakes it worse. She has never had a cough like this before andshe describes the cough as sharp. She produces white sputumwith her cough sometimes. She is concerned that she might havean infection and wants to feel better before her sisters weddingnext week. JS denies nausea, vomiting, diarrhea, fever, orabdominal pain.
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Written Documentation
Past Medical History (PMH) Childhood Illnesses: Multiple ear infections Adult Illnesses: None Hospitalizations: None Surgical History: Tonsils and Adenoids Removed,
1985
Medications: None Allergies: Penicillin (rash)
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Written Documentation
Family History (FH)Father: 50 (Type 2 Diabetes)Mother: 49 (Hypertension)Sister: 30 (Healthy)Children: NoneHistory of breast cancer on her fathers side of the
family
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Written Documentation
Social History (SH) Patient works as a bank teller and reports happiness
with her job. She enjoys traveling with her friends andcurrently denies financial or life stressors. She is not
sexually active and is currently not in a relationship.
She drinks 1-2 glasses of wine per week socially, but
denies tobacco or illicit drug use. She lives alone in anapartment currently and runs 1-2 miles per week.
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Written Documentation
Review of Systems (ROS) General: Patient denies fever, chills, night sweats, weight loss. Skin: Denies rash or new lesions. HEENT: Denies nose bleeds, sore throat, neck pain. Neck: Denies lumps, or stiffness. Cardiac: Denies chest pain, irregular heartbeat. Pulmonary: See HPI; denies, wheezing, hemoptysis, and pleuritic pain. GI: Denies vomiting, constipation, diarrhea, change in bowel habits, rectal bleeding or
jaundice.
Genitourinary: Denies dysuria, nocturia, hematuria, incontinence, or groin pain. Musculoskeletal: Denies, joint swelling, stiffness.
Neurologic: Denies headaches, numbness, weakness, difficulty walking, tremors Heme/immunology: Denies easy bruising, excessive bleeding, anemia, frequent infections.
Psychiatric: Denies suicidal/homicidal thoughts, difficulty concentrating, or feeling down.
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Objective
What you observe about the patient
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Written Documentation
Objective (O) Vitals General Appearance Physical Exam Laboratory Tests Diagnostic Tests
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Written Documentation
General : Well appearing female, appears stated age, comfortable, awake, alert. Vital Signs: Heart rate: 88 (regular) Temp 97.8F Weight 130lbs Height 58 BP supine, L arm, 130/80, reg cuff BP sitting, R arm, 125/85, reg cuff Skin: No rash. Normal skin turgor. Cardiovascular: PMI 5th intercostal space, midclavicular line, well localized, no
heaves, thrills. S1 normal intensity, A2>P2 with physiologic splitting. No gallops,clicks, murmurs or rubs. Capillary refill 3 seconds in bilateral hands. Pulses are 2+and symmetric in the bilateral brachial, radial, femoral, and dorsalis pedis pulses.
Pulmonary: Thorax symmetric, no increased A-P diameter, no use of accessorymuscles. Percussion resonant throughout. Auscultation reveals fine crackles in the
RLL otherwise clear. Labs: Troponin < 0.15 WBC: 6 Platelets: 300 ChestXray: No acute cardiopulmonary process
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Assessment
What you think is going on
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Written Documentation
Assessment Formulation Differential Diagnosis
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Written Documentation
Formulation Statement34 yr old female with no significant PMH who
presents with 1 week of a productive, sharp cough
without associated fever after traveling to Costa
Rica with fine crackles in the RLL on exam, likely
representing acute community acquired pneumonia.
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Written Documentation
Differential DiagnosisPneumonia vs. viral upper respiratory illness vs.
pulmonary embolism
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Plan
What you are going to do
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Written Documentation
Plan Diagnostic Tests Treatments Referrals Patient Education Follow-up
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Written Documentation
Tabular Will send patient for an
outpatient chest xray today.
Start Tessalon Pearls 100 mgPO twice daily for cough.
Will obtain blood work today inthe office including CBC andchemistry panel
If chest xray today reveals focalpneumonia, I will begin thepatient on Levofloxacin 750 mgPO once daily for five days.
Patient will return in 5 days for are-evaluation in the office beforeher sisters wedding.
Problem-based Cardiac Pulmonary GI Endocrine SkinNeurologic
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Closing
Make it official
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Written Documentation
Sign Date Time Contact
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Written Documentation
Addendums Corrections
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HISTORY & PHYSICAL
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History & Physical
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History & Physical
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History Writing Exercise
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History & Physical
CC
HPI
PMH
FH
SH
ROS
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History & Physical
General appearance Vitals Skin HEENT Neck Cardiovascular Pulmonary
Abdomen Rectal Genital Musculoskeletal Neurological Psychiatric Mini-mental status
exam
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General Appearance
Well nourished , welldeveloped
No acute distress Well-appearing vs.
ill-appearing
Younger vs. olderthan stated age
Tearful, comfortable
WN, WD NAD
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General Appearance
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Vitals
Height Weight
Body Mass Index Blood Pressure Pulse Respiratory Rate
Pulse Oximetry Visual acuity Hearing
Ht Wt BMI BP HR RR Pulse Ox
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Skin
Observe color Observe for dryness No rashes or unusual
moles
Normal hair and nailsNo petechiae, striae, orecchymoses
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HEENT
Head: Normocephalic, atraumatic (NCAT) Eyes: Conjunctiva clear, sclera non-icteric, no proptosis orlid lag; pupils equal, round, respond normally to light
and accommodation, extraocular movements intact,full visual fields to confrontation. Fundi: A:V ratio 2:3,no A-V nicking, no hemorrhages or exudates; disc
margins sharp without papilledema. (PERRLA, EOMI)
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HEENT
Ears: External auditory canals clear; tympanic membranestranslucent, with normal architecture, no erythema, dullness, orbulging. Hears finger rub. (TM)
Nose: Septum in midline, mucosa pink with no discharge, non-tender over frontal and maxillary sinuses. (NT)
Throat / Mouth: Mucous membranes moist, tonsils withouterythema or exudate. Uvula midline. Good dentition. (MMM)
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Neck
Supple. Full range ofmotion.
Trachea midline. Thyroid palpable:
small, smooth,
nontender, no masses.
Lymph nodes notpalpable bilaterally.
FROM
NT
LAD
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Cardiovascular
No jugular venous distention Point of maximal impulse at the
5th intercostal space in the mid-clavicular line, well localized.
No heaves, lifts, or thrills. Regular rate and rhythm. S1 normal intensity, A2>P2,
physiological splitting.
No murmurs, rubs, or gallops.
JVD PMI
RRR
m/r/g
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Cardiovascular
Nocarotid bruits. Pulses are 2+ and symmetric
bilaterally in the carotid,brachial, radial, femoral,popliteal, posterior tibial anddorsalis pedis regions.
Capillary refill less than 2seconds.
No lower extremity edema.
PT, DP
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Pulmonary
Breathing appears unlabored withno use of accessory muscles.
Thorax symmetrical, no increasedantero-posterior diameter. Equalexpansion.
No chest wall tenderness topalpation. Tactile fremitussymmetric. Resonant to
percussion.
Clear to auscultation bilaterally.No rhonchi, rales (aka crackles),wheezes, or rubs.
AP TTP
CTAB
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Breast
Symmetrical No nipple discharge No dominant masses No axillary
adenopathy
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Abdomen
Observe if flat, protuberant, ordistended
Note any scars Normoactive bowel sounds in all 4
quadrants, no renal or aortic bruits
Tympanic to percussion in all 4quadrants, no shifting dullness
Soft, non-tender, non-distended, nopulsatile mass, nohepatosplenomegaly
No costo-vertebral angle tenderness
NABS
NT, ND, HSM CVA
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Rectal
No hemorrhoids or fissures Normal tone Prostate not enlarged or
tender to palpation
No masses Stool is soft, brown, guaiac
negative
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Genitourinary
Male
Circumcised oruncircumcised
Testes descended, non-tender to palpation,without masses
No scrotal masses oringuinal hernias
TTP
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Genital/Pelvic
Female
Normal external genitalia Cervix clean and smooth Uterus anteverted. No
cervical motion tenderness
Adnexae non-tenderwithout masses
Cx CMT NT
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Musculoskeletal
Full range of motion inshoulders, elbows,
wrists, hands, hips,knees, ankles, and feet
(active vs. passive)
No redness, swelling, ortenderness of any joints
FROM
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Neurological
Cranial nerves: II-XIIsymmetric and intact
Motor: 5/5 motor strengthin all four extremities
Sensory: Sensationgrossly intact. Responses
to pain, light touch,pinprick, position, andvibration within normallimits.
CN
WNL
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Neurological
Cerebellar: Finger-to-nose andheel-to-shin within normal limits.
Alternating hand motion intact.
Reflexes: 2+ reflexes (biceps,triceps, brachioradialis, patellar,
achilles) bilaterally. Flexor plantar
response.
Gait: Toe, heel, and tandem walkis within normal limits. Able to
stand from chair without using
hands.
WNL
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Psychiatric
Folstein MMSE 30/30 Alert and oriented to
person, time, and place
Appropriate, normalaffect
A & O x 3
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Complete Physical
Writing Exercise
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History & Physical
General appearance Vitals Skin HEENT Neck
Cardiovascular Pulmonary
Abdomen Rectal Genital Musculoskeletal Neurological
Psychiatric Mini-mental status
exam
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SOAP NOTES
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Written Documentation
Full History and Physical (H&P) Progress Note (SOAP) Prescriptions Operative Report Consultation Report Radiology Report Discharge Report
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SOAP
S: Subjective O: Objective A: Assessment P: Plan
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CC, HPI, PMH, FH,SH, RO
PE, labs, imaging Formulation or DDx Tabular or problem-
based
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SOAP Notes
S: Subjective O: Objective A: Assessment P: Plan
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DOCTORING WRITE-UPS
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Doctoring Write-Ups
Mentor sites Authorship Faculty Professionalism
Case Write-Up Prescription Reflection
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Doctoring Write-Ups
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TOP TEN
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10. Never Use Patient Name
Initials are your friend
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9. Dont forget the CC
Use quotes
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8. Dont bore your reader
Balance thorough with succinct
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7. Incomplete history
Gather everything
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6. Disorganized ROS
Negative for what?
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5. No vital signs
They are vital for a reason!
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4. Incomplete PE
Be as complete as possible
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3. Redundancy
Say it once, right
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2. Disorganized PE
Head to toe
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1. No reflection or prescription
Reflect, prescribe, and prosper
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QUIZ!
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1. In the Doctoring course, case
write-ups should include what 3
components?
History & Physical
PrescriptionReflection
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2. When I need help with writing
case write-ups, what documents
are available for help?
Written Documentation Skills
Complete PE Answer Key
Excellent Case Write-Up Examples
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3. How do I know which
abbreviations to use in my case
write-ups?
CANVAS
Written Documentation Abbreviations
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Goals - Accomplished
I know what a Medical Record is I know the basics ofWritten Documentation I have written a full History and Physical I have an example of a progress note (SOAP) I Practiced a complete written history and physical I know the expectations of case write-ups in Doctoring
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Reminders
First Case Write-Up Due: Sunday, 9/8/13 6pm Bring a mentor case next week to class for OP Next week, start in small groups Professional attire
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