Medical Note-Taking & Documentation

• Study notes for documentation and note writing for Physical Diagnosis II.

Learning Objectives

• Understand general principles of documentation.
• Define components of a focused note.
• Organize pertinent positives and negatives in HPI, ROS, PE portions of note.
• Analyze information from subjective and objective portions of notes to develop a diagnosis.
• Develop a differential diagnosis.
• Develop the Assessment (old problem list).
• Document the Plan (patient management).
• Organize and perform an oral case presentation.

Principles of Documentation

• Documentation is essential to get paid.
• "Not documented--Not done."
• Medical records must be complete and legible.
• Patient encounters must include: reason for visit (CC), history, physical exam findings, diagnostic test results, clinical impression/diagnosis with differential diagnosis list, assessment (current and pre-morbid problem list), medical care plan, date, and provider identity.
• Rational for diagnostics need to be clear.
• Health risks must be identified.
• Patient progress and treatment response must be documented, with revisions.
• Diagnosis and treatment codes reported to health insurance must be supported by documentation.

Detailed Focus Note

• Identifying information is first and includes subjective data.
• Include the primary complaint and duration in the patient's words, with quotes if possible.
• The HPI should be a complete, full paragarph.
• Record of physical findings must match the same systems in ROS.
• Labs/Diagnostics that are resulted at the time of the note (numbered).
• Include Labs/Diagnostics only if completed by time of note.
• The list in your Assessment may list according to subjective material first followed by objective material.
• Pre-morbid conditions, harmful habits (ETOH), and pertinent family history (ETOH, mental illness) should also be added to your Assessment.
• The Plan should be numbered.

Identifying Information

• Should include the patient's name, age, DOB (XX/XX/XXXX format), and sex.

Chief Complaint (CC)

• The current problem should be stated, in the patient's words when possible, and it should include duration.
• Use direct quotes and quotation marks. Compliants should be listed as single words or short phrases with the approximate length of time they have been present (if possible).
• The CC is the starting place for making a differential diagnosis.

Subjective vs. Objective Information

• Subjective:*
• Historical information is from the patient. Includes the CC through the ROS.
• Example: "It feels like an elephant is sitting on my chest" (for ~1 hr).
• Objective:*
• Objective information should include findings identified from testing, lab, or diagnostic test info that has been resulted.
• Example: T 97.5 HR 100 RR 28 BP 160/80 02sat 99% Wt 180 Ht 5'10".
• Example: EKG: Sinus tachycardia.

Subjective Information Specifics

• CC:*
• Included in subjective data.
• HPI:*
• Based on the CC--OLDCART (Onset, Location, Duration, Character, Aggravating/Alleviating symptoms, Relieving/remitting, Timing, Severity)
• List 3-5 pertinent positives and negatives.
• HPI Grading:*
• Ensure to ask how long has the patient had the problem, the characteristic, quantity, what has he tried to relieve the pain? Document pertinent positives and negatives or any other information necessary.

Developing a Differential Diagnosis

• After obtaining the CC and start thinking of conditions.
• Narrow the list as you obtain pertinent positives and negatives.
• Further narrow differentials with vitals and physical exam findings.
• Select a primary or presumptive diagnosis after obtaining Labs/Diagnostics.
• Follow up with 4 differential diagnoses.

Diagnosis

• Differential Diagnosis
• Based on the CC
• The differential diagnosis should generate a list of at least five conditions.
• The primary diagnosis is the most likely and should be listed first.
• State a short explanation as to why the primary diagnosis was chosen.

Mnemonics for Diagnosis

• VINDICATE helps in generating a differential diagnosis.
• Vascular, Infectious, Neoplastic, Degenerative, Iatrogenic/intoxication, Congenital, Autoimmune, Traumatic, and Endocrine/metabolic etiology.

Subjective vs Objective Information

• Subjective:*
• PMH, FH, SH (barriers to care and tobacco exposure), review of systems.
• General system, Skin, Pulmonary, Cardiac must be included with every CC.
• Objective:*
• PE (top-down manner), vital signs (linear fashion), PE pertinent to CC.
• Labs/Diagnostics (numbered). Any lab/diagnostic completed and with resulted MUST be dated.

Note Pearls

• Always use the template format including system heading format with abbreviations.
• The HPI should be the ONLY paragraph in your note.
• Document in a top-down fashion, in the order you examine. "Head down-lungs before heart"
• Inspect/palpate/ROM.
• Labs/Diagnostics, Assessment, and Plan are numbered.

Psychic Note

• Sig E CAPS - Sleep, Interest, Guilt, Energy, Concentration, Appetite, Psychomotor activity, Suicidal Ideation.
• The neuro system is an additional and always needed for ROS.
• The neuro system is an additional system in PE for CSE's (MMSE, CN's, gross sensory, gross motor, and reflexes)
• Psych note includes: describe attitude, behaviors, activity, affect, thought processes, thought content, patient perception, insight, judgment, LOC, suicidal/ homicidal ideation, and reliability.

Assessment

• Declare your primary diagnosis with a short supportive statement.
• Your old problem list from the previous encounter becomes the assessment.
• Cluster information, including signs and symptoms (HPI), premorbid conditions (PMH), family history (FH), social history (SH), body systems (ROS), physical exam findings (vitals), and lab/diagnostic results during encounter.

Building an Assessment

• Patient’s signs and symptoms.
• Any pre-morbid conditions (tobacco or alcohol abuse).
• Any pertinent family history
• Any pertinent exposures.
• Positive findings on ROS.
• Any abnormal physical findings.
• Any abnormal lab results.

Assessment Pearls

• Address pre-morbid conditions/FH/exposure/unrelated symptoms reported to you in your plan.
• Address discovered conditions or patient reports.
• #1 Primary diagnosis with short supportive statement.
• #2 everything reported in HPI (positives).
• #3 everything discovered in PE/Labs & Diagnostics.
• #4 pre-morbid conditions, unhealthy habits, exposures, and pertinent family history related to illness.

Plan

• The documentation of anything medical or nonmedical you have placed on your assessment.
• Includes: patient disposition, diagnostic tests, therapeutics, consultations/referrals, premorbid conditions, patient education, prevention, and follow-up.
• Address barriers to care.
• Education will include anticipatory guidance, the expected prognosis, health promotion and disease prevention.
• Prevention includes diet needs, smoking cessation, and illicit drug use counseling.

Note Template

• Includes time/date, patient biographical data, name, DOB in 10/XX/XXXX form, sex, CC (in direct quotes, if possible include duration), HPI (paragraph form), OLDCARTS, associated symptoms, pertinent positives and negatives (3-5 each), PMH, FH, SH, and ROS.
• PE done in top down manner.
• VS in a linear fashion
• Include a short supportive statement.
• Include problem list( signs, symptoms, vitals, physical findings, resulted labs/diagnostics, premorbid conditions, pertinent social and family history
• Plan: Patient disposition, diagnostics, medications (be specific with medication) and non-pharmacologic, referrals/consults, pre-morbid conditions/relevant FH, SH, patient education/disease prognosis, prevention, follow up, barriers to care if any exist

Oral Case Presentation

• Should be a 5-7 minute verbal summary of patient encounter.
• State the CC
• Present the HPI with an introduction:. MJ is a 35-year-old male teacher, who has a known history of asthma, presents with a cough for 7 days.
• Expand on OLD CARTS
• PMH: significant for asthma as a teenager and a cold two weeks ago that he thought got better.
• Medication: took robutussin 2 days ago but did not help.
• NKDA, no known allergies to supplements or food
• Immunizations: Not taken the flu shot because heard it makes you sick
• FH: Mother and Father unknown (adopted)
• Sister age 30 significant for asthma
• SH: Significant for smoking which started 3 months ago (pack/wk)
• Negative for smoking marijuana or use of illicit drugs
• General: significant for fever of 101. 5 for 2 days and chills
• Skin: negative for lesions, rashes, or erythema
• HEENT: Eyes, non-contributory; Nose denies any nasal congestion, or rhinorrhea Respiratory: denies wheezing or hemoptysis
• Cardiovascular: denies chest pan, palpitation, PND, or orthopnea
• Giving only pertinents. Vital signs :BP 146/90,T 103.7F, RR 28 bpm, HR 102 bpm Gen'l: WDWN male who appears ill and is in mild distress
• Skin: no pallor, cyanosis,s or diaphoresis.
• HEENT -non-contributory
• Respiratory: good respiratory expansion.
• Labs/Diagnostics: AP/Lat CXR: +consolidation LLL
• List your DDX with rationale and at least 5 total possible differentials.
• If doing an oral presentation also include: synopsis in numerical fashion or the problem.
• Plan will include: What is your disposition? What diagnostic test will you offer?, What medications,referrals, or treaments? Finally, what is your followup plan, and education to them.