Title: It’s Midnight. You’re on call at DRH You have 3 patients waiting in the modules…
1Its Midnight.Youre on call at DRH You have 3
patients waiting in the modules
- How hard do you want to work for your
information?
2Appropriate Dictation Form and Content
- Clifford A Kaye M.D.
- Summer Lecture Series 2006
3Example 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.
4Example 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.
5Example 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.
6Example 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.
7Example 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.
8Goals 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.
9The 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
10Proper Form The 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
11Proper Form The Body of a Dictation
- Surgical History
- Social History including contact persons and
numbers - Pertinent Exam
- Dont bury pertinent findings in a lengthy normal
exam. - Pertinent Studies
- Labs
- Gram Stains
- Radiography
12Proper Form The 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.
13Proper Form The Body of a Dictation
- Hospital Course Organized by Problem
- Include details regarding baseline function
- Exit ABGs if applicable.
- Exit MMSE Neurological Exams if applicable.
14Proper Form The 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 patients CHF.
15Improper Form
- Repetition
- Misleading Information
- Unnecessary Information
16Repetition
- 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.
17Repetition
- 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.
18Repetition
- 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.
19Repetition
- 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.
20Repetition
- 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.
21Repetition
- 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
22Repetition
- 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 1100 p.m. on October 09,
2005. The patient was off the ventilator and at
1127 p.m., the patient went into
cardiorespiratory arrest and expired. The
patient was declared dead around 1130 p.m., his
pupils were fixed...
23Misleading Information
- 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.
24Misleading 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.
25Misleading 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
26Misleading 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.
27Unnecessary 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
28Prose
29Prose
- 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 .
30Prose
- 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.
31Prose
- 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.
32Prose
- 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.
33Prose
- 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.
34Proper Form
- Abnormal Labs Only
- Priceless Information Regarding
- Cognitive Disorders
- Personality Disorders
- Baseline Function
- Social History
- DIGESTION of your workup
35Pertinent 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.
36Priceless 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. NEUROLOGICThe 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.
37Priceless 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. NEUROLOGICThe 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.
38Priceless 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.
39Priceless 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.
40Priceless 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.
41Priceless 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.
42Priceless 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.
43Priceless 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.
44Priceless 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.
45Priceless 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 youre asking the next team to do that work.
46Precision
- 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
47Precision
- 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 530 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 915 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.
48Precision
- 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 830 a.m. The
phone number for contact is 313-745-2626. - CONDITION ON DISCHARGE Stable to home.
49Precision
- .
- 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??
50Proper 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.
51Improper OrganizationIncomplete Data 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.
52Improper 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.
53Improper 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.
54Improper 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.
55The 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
56- If you dont know your destination
- every road will take you there
57The 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
58Proper Form The 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
59Proper Form The Body of a Dictation
- Family Surgical Histories
- Social History including contact persons and
numbers - Pertinent Exam
- Dont drown pertinent findings in a normal exam.
- Pertinent Studies
- Labs
- Gram Stains
- Radiography
60Proper Form The 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.
61Proper Form The 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 patients CHF.
62Proper Form The 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 patients CHF.
63Proper Form The 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
64JCAHO 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.
65When 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
66Who Should Dictate?
- A physician who knows the patients hospital
course
67Exit To Your Right
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