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Documentation
The other cornerstone of
Western medicine
Initial thoughts. . .
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Documentation is essential to providing skilled
medical care. . .
Serves a variety of purposes:
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Provides written record of presentation, evaluation,
and treatment – to be reviewed by oneself or by
consultants
Allows for formal chart review of appropriate care
and documentation – “peer review”
Provides written proof of patient consent, medication
instructions, etc.
Directs support staff in the care of the patient
Peer Review
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A formal evaluation of a certain
percentage of a physician’s work
Performed on a regular basis at almost all
U.S. medical institutions
A physician’s peers review outpatient and
inpatient records for clarity, accuracy,
appropriate documentation, and provision
of standard of care medicine.
So, what exactly do
physicians document?
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Patient care related documentation
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The “Notes”
Admission and Discharge
The “Orders”
Legal Documentation and Consent
Administrative Documentation
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Routine admission, disposition forms
Birth and Death certificates
Insurance or billing paperwork
The Notes
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An abbreviated notation of the facts – similar to
the “notes” one might take during a lecture and
refer to while studying before a test
Allows colleagues and other medical personnel a
chance to review the case
Allows oneself a chance to review initial
presentation and evaluation
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In later review of the chart one often finds subtle
areas previously left unexplored
The Notes
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In addition to recording Subjective and Objective
portions of the patient presentation,
documentation allows the physician to convey
his or her own thoughts on the case – this is
done in the Assessment portion of the note
Next, the physician documents their Plan for
further diagnostic study and/or treatment
The Notes
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Careful attention is paid to internal consistency
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is not necessary to explain every single laboratory
test or treatment modality in detail
 It is necessary to provide ample facts such that any
competent physician would be able to easily deduce
your reasoning
Finally, the fact that you discussed your
thinking, the plan, and the expected outcome
with your patient is documented
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Ms. Fukai, a 23 y/o o/w healthy Japanese ♀, presented today for ℅ acute onset R ear pain following daily
swimming in the local pool over the previous week. Pt. has exp’d 36 hrs ↑’ing R otalgia assoc. w/ ↑’ing mucoid
d/c. Afebrile and w/o any signs or symptoms of illness. Denies trauma/diving.
Meds: Eucerin, occasional topical hydrocortisone 2% ointment
Allergy: NKDA
PMH/PSH/FH: Atopic dermatitis well controlled on current tx. o/w N/C
Soc Hx: No tobacco, occasional EtOH (<2 drinks per week)
VS’s:
GEN:
HEENT:
LUNGS:
CV:
SKIN:
Dx:
T=37°C, P=68, RR=12, BP=120/64
Alert, NAD
PERRLA/EOMI – B Nares patent/NL turbinates, L TM Θ with + movement to insufflation,
R TM partially visualized and mobile to insufflation with + mucoid otorrhea in canal, + pain
on manipulation of right pinnae, neck supple/Θ lymphadenopathy
CTAB
RRR without M/R/G NL S1/S2
Warm, moist – Ø evidence of atopic Δ’s
Otitis Externa 2° to excessive H2O exposure
Plan: Ofloxacin otic – 6-8 drops AD TID X 7 days
Avoid H2O exposure throughout duration of tx
RTC if discharge/pain ↑’s, swelling of neck/face, no response to tx
Discussed etiology, pathophysiology, medication use, f/u
Patient expresses understanding and concurrence
Andrew W. Schiemel, MD, FAAP
Shorthand from previous slide
y/o
o/w
♀
℅
R
exp’d
hrs
↑’ing
assoc
w/
d/c
w/o
NKDA
tx
N/C
EtOH
NAD
PERRLA
EOMI
=
=
=
=
=
=
=
=
=
=
=
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=
=
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=
=
=
=
years old
otherwise
female
complaint of
right
experienced
hours
increasing
associated
with
discharge
without
no known drug allergies
treatment
non-contributory
alcohol
no acute distress
pupils equal round and reactive to light and acc.
extra ocular movement intact
Shorthand continued
B
L
TM
Θ
+
CTAB
RRR
M/R/G
NL
S1/S2
Ø
Δ’s
Dx
2°
H2O
AD
TID
X
RTC
↑’s
f/u
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
=
bilateral
left
tympanic membrane
negative
positive
clear to auscultation bilaterally
regular rate and rhythm
murmur, rub, gallop
normal
first and second heart sounds
no (none)
changes
diagnosis
secondary
water
aure dextra (right ear)
three times per day
for (X 7 days = for seven days)
return to clinic
increases
follow up
Review of sample note
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Clearly explains the patient’s presentation and
makes reference to the patient’s overall
health/medication use, etc.
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Pertinent positive and negative historical and
physical facts are included.
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Although sufficient information to rule-out every
known cause of otorrhea is not included, one
can adequately discern between the two main
diagnostic possibilities (otitis externa or ruptured
tympanic membrane) with the information
provided.
Review of sample note
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Working diagnosis and treatment plan are clearly and
succinctly laid out
Exact medication directions are recorded, including dose,
route, frequency, and duration of therapy.
Indications for returning to the clinic are addressed and
the physician notes that the patient expresses
understanding and acceptance of the plan.
Finally, the chart entry is signed and dated – with the
physician’s printed name provided for accuracy.
Admission and Discharge
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Admission H&P’s and discharge summaries are
perhaps the most tedious of all medical
documentation.
Standard pre-printed forms for each are in
common use so that important details are not
overlooked.
The assessment portion affords the physician
the opportunity to express the logic effecting
specific decisions.
Admission and Discharge
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The assessment is often written as a narrative.
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The physician may report competing diagnoses,
concerns regarding reliability of diagnostic testing or
treatment side effects, anticipated outcome, etc.
The plan portion of the admission paperwork
typically lays out a variety of diagnostic and
treatment actions.
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Essentially, it is a list of tasks to be accomplished
during the admission.
One should include “indications for discharge” in
every admission plan.
Admission and Discharge
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The discharge summary is simply a wellorganized running dialogue that delineates the
patient’s presentation, hospital stay, and
condition on discharge
First, details regarding the initial presentation
are summarized
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Strict delineation of subjective opinions from objective
facts is often overlooked
Instead, the key here is to summarize the basics of
the presentation so that anyone reading the discharge
summary understands how you arrived at your
admitting diagnosis
Admission and Discharge
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Secondly, the physician outlines the patient’s
hospital stay, remarking on general trends
observed from day to day – hopefully ending in
resolution of disease or significant improvement.
If, for example, the patient was steadily weaned
from supplemental oxygen, there is no reason to
list out a variety of pulse oximetry readings and
subsequent changes to oxygen delivery.
Admission and Discharge
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Instead the physician simply states:
“Throughout the admission, supplemental oxygen
initially supplied at 10LPM via non-rebreather face
mask - was weaned entirely. At discharge the patient
was consistently saturating >98% via pulse oximetry
on room air alone.”
The Orders
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Physician orders are written instructions for
patient care.
Historically the physician’s orders were written
using medical shorthand in an effort to save
time.
Recently, however, there has been a push to
revise this system and allow for minimal
abbreviation use due to concerns regarding
medication and treatment errors.
The Orders
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Inpatient charting involves two varieties of
medical orders – admission or transfer orders
and daily orders.
In an effort to remember all the specifics of
admission orders, students and junior staff alike
use the acronym, ADCVAANDIMLS
pronounced “A-D-C van Dim-els”
The Orders
Admit to – Physician notes the specific location within the hospital
where the patient should be admitted
Diagnosis – The working diagnosis or diagnosis to be excluded
Condition – One word reference to the patient’s general condition –
e.g. Good/stable/guarded or poor/fair/critical
Vital signs – Frequency of vital signs is listed - to include mention of
any continuous monitoring such as
cardiorespiratory monitor (CRM) – standard orders
involve “q shift” or “every shift” vital signs –
indicating that they are to be taken at change of
the nursing shift
Allergies – Patient medication allergies are listed (if none, no known
drug allergies (NKDA) is listed
The Orders
Activity – Allowable patient activity is listed here (e.g. bed rest, bed
rest with bathroom privileges, normal activity, limited
activity, etc.)
Nursing – Any specific nursing instructions (e.g. change patient
position every 4 hours to avoid bed sores, sponge bath
every morning, record fluid intake and output (strict I/O’s),
indications to call on-duty physician such as “call medical
officer for temperature greater than 39.5 degrees,” etc.)
Diet
– Allowable diet for patient (e.g. nothing by mouth (NPO),
clear liquids (no solids), full liquids, soft diet, soft
mechanical, regular, American Dietary Association 2000
calorie diet (ADA 2000), low-sodium, low protein, lactose
restricted, etc.)
The Orders
IV fluids – Standard orders for intravenous (IV) fluids are listed here;
although every admission does not involve IV fluid
administration, this section allows for a dedicated space
to indicate such therapy. Attention should be paid to
details regarding the fluid composition, the volume to be
given and the rate at which the fluids are to be run.
Medications – Standing medication orders – that is, medication to be
taken on a recurring basis throughout the admission;
be sure to mention dosage, frequency, route, and
indication where appropriate (e.g. acetaminophen
500 milligrams by mouth every 8 hours as needed for
fever)
The Orders
Labs – This includes laboratory or radiological studies to be ordered
at the time of admission and/or any recurrent lab/rad orders
(e.g. 1. Acute abdominal series at admission, 2. CBC with
differential count every morning, etc.)
Special – Any orders that are non-medical in nature (e.g. patient
may have off-ward privileges during the day. Or perhaps,
patient does not want any visitors)
The Orders
• Transfer orders follow this same format,
however the orders begin with “Transfer to
______” instead of “Admit to _____.”
As the patient is being sent to an entirely
different section of the hospital, all orders must
be re-written.
Simply writing a one-line order for “Transfer
patient to ______” is not sufficient.
Legal Documentation
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Remember, the entire chart is a legal document – this is
not only the physician’s personal record of patient care –
it is also available for perusal by the ancillary staff, the
patient, or the patient’s lawyer!
Written consent for invasive procedures or
experimental/chemotherapeutic medication use is
commonplace in Western medicine
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Forms document specific discussion regarding indication,
procedural or treatment plan, and possible complications
Legal Documentation
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Verbiage is included that indicates the patient’s understanding of
these issues as well as a willingness to undergo the planned
procedure or therapy
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This form is then signed and dated by both patient and physician
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Additionally, a witness to the patient’s signature and verbal
agreement is present and signs the form
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This person should not be a direct member of the team which will
perform the procedure or treatment
Legal Documentation
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Operation reports and procedural notes are another form
of legal documentation
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The specifics of the procedure or operation are documented in
painstaking detail with reference to prepping, draping, sterile
technique, and the like
Finally both anticipated results and unanticipated complications
are addressed
For example, a procedural note for lumbar puncture in a
1-month-old infant might look like this:
Lumbar Puncture Consent
Written consent was obtained and all aspects of the procedure were
discussed at length with the family to include indication, procedural
technique, and possible complications. The infant was prepped and
draped in sterile fashion and sterile technique was followed throughout.
A 24 gauge spinal needle was introduced into the spinal canal at the
L3/L4 intervertebral space using standard accepted technique – only
one attempt was necessary to obtain cerebrospinal fluid (CSF) sample.
Approximately 8 ml of CSF was obtained and sent for standard
chemistries, cell count, gram stain and culture. Skin site was cleaned
and sterile dressing was applied. Infant tolerated the procedure well.
There was no blood loss or complication.
Legal Documentation
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Some legal documentation serves only to avoid potential
litigation and has no medical purpose – One such example is
the documentation of a patient leaving against medical advice
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This process of self-removal from the inpatient hospital
environment is referred to as “leaving against medical advice” or
simply AMA
Patients who wish to leave the hospital against the physician’s
wishes are asked to sign a form that clearly states the same
This documentation attempts to lessen the likelihood of
litigation against the physician or hospital should the patient
suffer a bad outcome as a result of early discharge
Administrative documentation
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Purely administrative forms include routine
paperwork associated with admission, transfer or
disposition
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Additionally, completion of birth and death
certificates, as well as insurance forms, can be
considered mostly administrative tasks
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Typically these forms will require only the physician’s
signature, as the details will have been filled in
previously by the administrative support staff
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Needless to say, as in any situation where your signature
certifies acceptance of whatever it is you are signing, it is
important to review the information on the form for
accuracy before signing
Basic Tenets of Documentation
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Pay attention to prose
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The most basic requirement of medical documentation is
not dissimilar to the basics of any effective writing –
penmanship, word choice, and grammar are of paramount
importance
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In documenting the patient encounter, one must ensure
that the text is legible – an unintelligible entry is useless
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Unlike oral presentation, written documentation allows for
(and encourages) the use of acronyms and abbreviations
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Nonetheless, a physician’s written assessment should
reflect a sharp medical intellect and a graceful literary style
Basic Tenets of Documentation
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Be efficient
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Medical records and outpatient chart entries should summarize
presentation, evaluation, and care rendered in the most efficient
manner possible
The documentation of the most minute detail is often
unnecessary – an abridged version of the story often is most
appropriate
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With time and experience students learn to master the art of
documenting a condensed version of the case
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The use of accepted acronyms and abbreviations also allows for
more concise documentation
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Students and staff alike should avoid using arcane or little known acronyms
or abbreviations
Basic Tenets of Documentation
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Do not sacrifice details for space considerations
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In focusing your documentation, be sure to include all relevant
information – leaving out important details in an effort to
conserve space is a mistake that should be avoided
Early on in your career it is best to err on the side of including
too much information rather than overlooking vital details in an
effort to be concise
With regard to history and physical this translates into the
recording of pertinent positives and negatives – inclusion of
everything the patient may have said and the entire physical
examination is usually unnecessary
Reasoning behind medical treatment or surgical intervention
should be recorded clearly
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The medical record should allow any reasonably experienced member of the
medical team to understand your thinking.
Basic Tenets of Documentation
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Ensure that the information flows logically
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Regardless of the case complexity or medical setting,
documentation should follow a logical pattern
That is, the basic design of the patient encounter
should be reflected in the documentation – just as it
is in case presentation
Historical facts should be recorded first, with physical
findings and diagnostic studies following next
Basic Tenets of Documentation
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Organize your thoughts
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Documentation format typically reflects case
complexity
Straightforward outpatient (and sometimes inpatient)
charting is organized using the standard S.O.A.P.
format while cases of limited complexity are typically
organized by problem
Significantly complex inpatient care is usually
documented utilizing a “by system” approach
S.O.A.P – Straightforward
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Subjective, Objective, Assessment, and Plan
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This is by far the most commonly used documentation format –
as the vast majority of medical practice involves the diagnosis
and treatment of common disorders in an outpatient setting
As with presentation, clearly delineating the subjective and
objective portions is required
Within the standard SOAP format, the assessment is often
simply a notation of the diagnosis and possibly an indication of
the exact etiology
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The plan is typically a numbered listing of items comprised of
treatment, patient education, and follow-up
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Often the assessment and plan are listed together as “A/P” and
the entry that follows is a hybrid of the two
S.O.A.P – Straightforward
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S)
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O)
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33-year-old o/w healthy ♂ with c/o 4-day h/o ↑’ing bilateral eye irritation and discharge.
Afebrile - o/w healthy – no chronic medical conditions. + contact with friend
experiencing similar sx’s
GEN:
HEENT:
PERRLA -
Alert, NAD
Bilateral scleral injection and conjunctival hyperemia
+ mucoid discharge/crusting at lid margin
EOMI  no pain with movement of eye, NL visual fields - Vision 20/20
No evidence of peri-orbital edema
A/P) Conjunctivitis – viral vs. bacterial
 High probability of viral etiology, however, given increasing symptoms and nonverification of bacterial source via culture, will treat empirically for likely bacterial
pathogens
 Polymyxin B / SUL-TMP ophth soln  4 drops in each eye QID X 5 days as
directed
 RTC if sx’s worsen or persist greater than 5-7 days without improvement, eye pain
develops, or visual deficit occurs
 Dx, etiology, prognosis, disease course, med use/side fx, and hygiene discussed
with patient at length
By PROBLEM – Limited Complexity
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In an effort to maintain adequate organization in cases
of limited to moderate complexity, a “by problem”
approach is used to document the assessment and plan
As discussed earlier, the historical and physical data
format (subjective and objective) rarely changes,
regardless of complexity
Quite simply, the by problem approach involves listing
out the patient’s individual problems or diagnoses and
documenting an individual plan for each
“By problem” Assessment and Plan
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A/P)
Atopic dermatitis
Acute treatment of symptomatic flare with topical hydrocortisone 2.5%
ointment TID for 10 days
Regular and liberal use of emollient each day – applied at a minimum in the
morning, after water exposure, and before bed
Mild Persistent Asthma
Continue BID use of inhaled corticosteroids as maintenance therapy
Albuterol MDI 1-2 puffs via spacer q4-6 hours prn cough, chest tightness, etc.
 RTC/ER if required > q4h
Allergic Rhinitis
Continue nasal corticosteroid inhaler at one spray each nostril qHS for
maintenance
Patient to follow-up in 6-8 weeks for ongoing care of above – RTC sooner for
any increased symptoms or concern
By SYSTEM approach – Complex
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A by system documentation style is reserved for the
most complex medical patients
Traditionally the subjective and objective data remains at
the initial portion of the chart entry, with the assessment
and plan alone broken down into systems.
In extremely complex and heavily-detailed cases, even
the subjective and objective portions may be broken
down into systems!
“By problem”
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FEN: Pt has 18 gauge IV site in left antecubital fossae.
Full maintenance IVF while NPO awaiting angiocath.
Strict monitoring of I/O’s. Chem 7 qAM. Adequate urine
output over past 24 hours.
CV: Patient with significant history of cardiovascular
disease. HTN controlled with daily ACE-inhibitor therapy,
history of stable angina with symptomatic relief provided
with nitroglycerin sublingual tabs. On exam, patient has
RRR with no evidence of M/R/G. Distal pulses are
strong. HR is 64 and BP is 140/88. Plan for continued
outpatient medication therapy while admitted with strict
monitoring of BP (as he remains high-normal despite
medication).
Classic systems used in documentation
include. . .
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FEN: Fluid, electrolytes, nutrition
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HEENT: Head, eyes, ears, nose, throat
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CV: Cardiovascular
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PULM: Pulmonary
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GI: Gastroenterological
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GU: Genitourinary
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NEURO: Neurological
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DERM: Dermatological
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MS: Musculoskeletal
By SYSTEM approach – Complex
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A by system approach is commonly reserved for
intensive care unit documentation
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However, exceptionally ill ward patients may require a by
system approach as well
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As ward patient complexity increases and a by system
approach becomes increasingly warranted, you may also
want to consider transferring the patient to an intensive
care unit setting!!
S
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Final thoughts. . .
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Adherence to the principles presented here will guide
you toward skillful documentation
Students should bear in mind that the goal of
documenting patient care is simply to create a clear and
concise record of the patient’s presentation, evaluation,
and treatment
Staying focused on this objective will allow you to
develop proficiency in documentation – thus adding
another valuable tool to your medical arsenal
Questions??