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

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Its Midnight.Youre on call at DRH You have 3
patients waiting in the modules

• How hard do you want to work for your
  information?

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Appropriate Dictation Form and Content

• Clifford A Kaye M.D.
• Summer Lecture Series 2006

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Example 1(page 1)

• DISCHARGE DIAGNOSIS Congestive heart failure
  exacerbation.
• PROCEDURES
• 1. Paracentesis.
• 2. CT scan of the abdomen and pelvis.
• 3. 2D echo of the heart.
• CHIEF COMPLAINT Shortness of breath.
• HISTORY OF PRESENT ILLNESS A 52-year-old
  African-American male with history of CHF who is
  HIV positive. He had a recent hospitalization at
  an outside institution. This hospitalization was
  for pneumonia. The patient did receive
  antibiotics at that time. The patient presents
  with a one week worsening of shortness of breath
  over his baseline shortness of breath. He also
  complains of cough productive of whitish sputum
  during that time. He has had fevers and chills.
  He has had orthopnea. He has had PND. The
  patient states that he has been compliant with
  all of his medications including antihypertensive
  medications. On the day of admission, the
  patient was sitting on the couch and had an
  episode of shortness of breath associated with
  some left-sided chest pain which was
  nonexertional and pleuritic in nature.

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Example 1(page 1)

• DISCHARGE DIAGNOSIS Congestive heart failure
  exacerbation.
• PROCEDURES
• 1. Paracentesis.
• 2. CT scan of the abdomen and pelvis.
• 3. 2D echo of the heart.
• CHIEF COMPLAINT Shortness of breath.
• HISTORY OF PRESENT ILLNESS A 52-year-old
  African-American male with history of CHF who is
  HIV positive. He had a recent hospitalization at
  an outside institution. This hospitalization was
  for pneumonia. The patient did receive
  antibiotics at that time. The patient presents
  with a one week worsening of shortness of breath
  over his baseline shortness of breath. He also
  complains of cough productive of whitish sputum
  during that time. He has had fevers and chills.
  He has had orthopnea. He has had PND. The
  patient states that he has been compliant with
  all of his medications including antihypertensive
  medications. On the day of admission, the
  patient was sitting on the couch and had an
  episode of shortness of breath associated with
  some left-sided chest pain which was
  nonexertional and pleuritic in nature.

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Example 1(page 2)

• PAST MEDICAL HISTORY HIV for approximately 20
  years. The last CD4 count is120. The patient is
  not taking any HAART therapy. Hypertension and
  CHF.
• OUTPATIENT MEDICATIONS Avelox, Zocor, Bactrim,
  and a diuretic.
• ALLERGIES HE IS NOT ALLERGIC TO ANY
  MEDICATIONS.
• FAMILY HISTORY Includes diabetes mellitus type
  2 and hypertension. Also
• myocardial infarction in the mother and father in
  their 60s.
• SOCIAL HISTORY Significant for cocaine use.
  Last use was within the last 3-5 days prior to
  admission. No IV drug use. No alcohol use. No
  smoking of tobacco. The patient lives alone in
  an apartment.

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Example 1(page 2)

• PAST MEDICAL HISTORY HIV for approximately 20
  years. The last CD4 count is 120. The patient
  is not taking any HAART therapy. Hypertension
  and CHF (Still not specific)
• OUTPATIENT MEDICATIONS Avelox, Zocor, Bactrim,
  and a diuretic.
• ALLERGIES HE IS NOT ALLERGIC TO ANY
  MEDICATIONS.
• FAMILY HISTORY Includes diabetes mellitus type
  2 and hypertension. Also
• myocardial infarction in the mother and father in
  their 60s.
• SOCIAL HISTORY Significant for cocaine use.
  Last use was within the last 3-5 days prior to
  admission. No IV drug use. No alcohol use. No
  smoking of tobacco. The patient lives alone in
  an apartment.

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Example 2

• CHIEF COMPLAINT Altered Mental Status, per
  nursing home.
• PRINCIPLE DIAGNOSIS Delerium due to UTI.
• DISCHARGE DIAGNOSES
• 1. Multi-infarct
  Dementia
• 2. Hepatitis.
• 3. Diabetes type
  2.
• 4. Incontinence.
• 5. Prostate
  cancer.
• CONSULTS Consults were to orthopaedic surgery,
  radiation oncology, psychiatry, occupational
  therapy, physical therapy, neurology, urology,
  and social work.

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Goals Objectives

• Teach the utility of discharge dictations as a
  means to communicate clear concise clinical
  data.
• What data to include and exclude.
• How to organize the data.
• When to dictate.
• Who should dictate.

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The Data

• Include
• Concise information.
• Pertinent labs
• Priceless Information
• Medication List
• Follow-up Instructions
• Psych/Cognitive Disorders
• Baseline Exams

• Exclude
• Repetition
• Normal Labs
• Prose
• Inaccurate Information
• From the Patient
• From the Chart

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Proper 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

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Proper 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

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Proper 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.

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Proper 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.

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Proper 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.

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Improper Form

• Repetition
• Misleading Information
• Unnecessary Information

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Repetition

• DATE OF ADMISSION 10/06/2005
• DATE OF DISCHARGE 10/09/2005
• ADMITTING DIAGNOSES
• 1. Abscess with methicillin-resistant
  Staphylococcus aureus.
• 2. Urinary tract infection due to
  methicillin-resistant Staphylococcus aureus.
• 3. Central respiratory failure due to brainstem
  radiotherapy.
• 4. Anemia.
• 5. Fever, leukocytosis.
• 6. Syndrome of inappropriate antidiuretic
  hormone.
• 7. Neurofibromatosis.
• 8. Sepsis.
• DISCHARGE DIAGNOSIS
• Central respiratory failure
• Pneumonia, methicillin-resistant Staphylococcus
  aureus sepsis.
• __________ collapse.
• Anemia.

• 1

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Repetition

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

• 2

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Repetition

• After completion of antibiotic on September 23,
  2005, he had another fever spike and was started
  on empiric Zosyn and tobramycin. Basically, he
  was admitted for infection control, his sepsis,
  and for ventilation settings. He was discharged
  from Children's Hospital in Detroit with Zosyn,
  tobramycin, phenobarbital, labetalol,
  subcutaneous heparin and multivitamins.
• PAST MEDICAL HISTORY Congenital
  neurofibromatosis diagnosed at six weeks of age,
  amputation of left leg at seven years old. At
  age 13, he had radiotherapy for bilateral optic
  tumors. In 1987, he had removal of posterior
  fossa astrocytoma and one week later first
  cerebrospinal fluid shunt was put. Between 1987
  and 1996, he had six shunt revisions. Between
  January 2005, and March 2005, he had another six
  more shunt revisions. He has a history of grand
  mal seizures. In March 2005, he had hemorrhagic
  stroke. In August 2005, on MRI it was found that
  he had another brainstem tumor and he completed
  ten days of radiotherapy. A PIC line was placed
  two weeks ago at another Children's Hospital and
  feeding tube was placed one month ago after two
  weeks of nasogastric tube feeding.
• FAMILY HISTORY History of neurofibromatosis in
  the mother.
• PAST SURGICAL HISTORY As stated above.

• 3

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Repetition

• 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.

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Repetition

• HOSPITAL COURSE The patient is a 30-year-old
  Caucasian male with a past medical history of
  congenital neurofibromatosis. He was transferred
  from one of the Children's Hospital in Detroit
  with a diagnosis of sepsis with
  methicillin-resistant Staphylococcus aureus as
  well as anemia and for adjustment of his
  ventilation settings.
• 1. Infectious disease. At another Children's
  Hospital, he had a history of vancomycin
  resistant urinary tract infection and
  methicillin-resistant Staphylococcus aureus
  tracheal bronchitis and pneumonia. So we started
  him on __________ 500 mg intravenous every twelve
  hours and cefepime, tobramycin for possible
  hospital acquired pneumonia.
• We consulted ID and Neurosurgery for a possible
  shunt infection.. ID was consulted and they
  recommended to start Flagyl as well. Blood
  cultures continued to grow out gram positive
  cocci in clusters in aerobic bottle. An echo was
  done to rule out endocarditis and it was
  negative. Ejection fraction was 60.
• Since the blood cultures showed gram positive
  cocci, we started him on
• vancomycin later and we had a CT scan of the head
  that showed sinusitis
• bilaterally, so we started him on moxifloxacin
  and consulted ENT for sinusitis
• management. They removed the PIC line.

• 4

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Repetition

• 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

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Repetition

• 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...

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Misleading 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.

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Misleading Information

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

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Misleading Information

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

FOB Results
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Misleading Information

• Hospital course
• 2-The patient came in with an elevated WBC-16.9
  with neutrophilia and thrombocytosis-probably
  reactive thrombocytosis WBC on discharge was
  11.5 . Platelet count 991. Afebrile .Discharged
  on levofloxacin.
• 3.Patient was discharged with a diagnosis of post
  obstructive pneumonia and will follow up for
  further investigation on out-patient basis. He
  might need repeat bronchoscopy to rule out
  malignancy or other cause for the right upper
  lung infiltrate and weigthloss. The patient was
  discharged in stable condition.

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Unnecessary Information

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

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Prose
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Prose

• FINAL DIAGNOSIS New onset diabetes mellitus.
• SECONDARY DIAGNOSES
• 1. Hypertension.
• 2. Hypertriglyceridemia.
• CHIEF COMPLAINT This patient was admitted with
  the chief complaint of drinking a lot, draining a
  lot, and blurring vision.
• HISTORY OF PRESENT ILLNESS The patient is a
  51-year-old man with a past medical history of
  hypertension and chronic back pain who presented
  to the emergency department complaining of two
  months of polyuria, polyphagia, polydipsia,
  nocturia, blurring vision. The patient states
  that he has many family members with diabetes and
  recognized these symptoms he was having as being
  caused by .

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Prose

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

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Prose

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

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Prose

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

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Prose

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

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Proper Form

• Abnormal Labs Only
• Priceless Information Regarding
• Cognitive Disorders
• Personality Disorders
• Baseline Function
• Social History
• DIGESTION of your workup

35
Pertinent Labs

• DATE OF ADMISSION 10/27/2005
• DATE OF DISCHARGE 10/31/2005
• FINAL DIAGNOSIS Acute lobar
  nephronia/ early renal abscess.
• HISTORY OF PRESENT ILLNESS The patient is a
  27-year-old African-American female with no
  significant past medical history..
• FAMILY HISTORY The patient's father had cancer,
  unknown type.
• SOCIAL HISTORY .
• PHYSICAL EXAMINATION .
• LABORATORY DATA White count 16.1, hemoglobin
  9.4. The patient had a normal chem-7. Amylase
  was normal at 50. Pregnancy test was negative.
  Liver function tests were normal. Urine drug
  screen was negative. UA was positive for 2
  bacteria, trace leukocyte esterase, positive
  nitrites, 5 to 10 WBCs.

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Priceless InformationCognitive Disorders

• PHYSICAL EXAMINATION VITALS Blood pressure
  152/100, heart rate 83, respiratory rate 16,
  temperature 97.8. GENERAL He is an elderly
  African- American gentleman, in restraints when
  seen. He appears confused but in no acute
  distress. CARDIOVASCULAR Positive for a
  pacemaker in the right upper chest, otherwise
  within normal limits. LUNGS Within normal
  limits. NECK Within normal limits. ABDOMEN
  Basically normal. Bowel sounds positive. No
  tenderness or distention. No rebound tenderness.
  No CVA tenderness. RECTAL Tone normal.
  Temperature normal. The prostate had an
  irregular surface. The rectum was full of hard
  stool, but there was no blood, no secretions, no
  signs of hemorrhoids and no pain. No perianal
  lesions or ulcerations. 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.

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Priceless InformationCognitive Disorders

• PHYSICAL EXAMINATION VITALS Blood pressure
  152/100, heart rate 83, respiratory rate 16,
  temperature 97.8. GENERAL He is an elderly
  African- American gentleman, in restraints when
  seen. He appears confused but in no acute
  distress. CARDIOVASCULAR Positive for a
  pacemaker in the right upper chest, otherwise
  within normal limits. LUNGS Within normal
  limits. NECK Within normal limits. ABDOMEN
  Basically normal. Bowel sounds positive. No
  tenderness or distention. No rebound tenderness.
  No CVA tenderness. RECTAL Tone normal.
  Temperature normal. The prostate had an
  irregular surface. The rectum was full of hard
  stool, but there was no blood, no secretions, no
  signs of hemorrhoids and no pain. No perianal
  lesions or ulcerations. 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.

38
Priceless InformationSocial HistoryPage 1

• DATE OF ADMISSION 09/13/2005
• DATE OF DISCHARGE 09/16/2005
• PRIMARY DIAGNOSIS Congestive heart failure
  exacerbation secondary to pneumonia.
• SECONDARY DIAGNOSES
• 1. Hypertension.
• 2. Congestive heart failure.
• 3. Hepatitis C.
• The only procedure performed on the patient was
  an echocardiogram.
• PROBLEM LIST
• 1. Pneumonia.
• 2. Congestive heart failure.

39
Priceless InformationSocial HistoryPage 2

• HISTORY OF PRESENT ILLNESS The patient is a
  53-year-old African-American male with a past
  medical history of CHF, hypertension and
  hepatitis C. The patient is often medically
  noncompliant and has multiple hospital
  admissions. Last night the patient became short
  of breath, coughing at night, could not eat, and
  decided to prophylactically come to visit the
  hospital. No fevers, no chills, no night sweats,
  no weight loss. No chest pain, no abdominal
  pain, no diarrhea, no constipation. No leg pain.
  The patient can walk at baseline half a block
  and the patient can walk up four individual
  stairs. The patient sleeps on five pillows. He
  does have orthopnea, PND twice a night recently
  that increased to four times a night. The
  patient denies any sick contacts or temperatures
  at home.
• MEDICATIONS At home, the patient takes
  Lopressor 50 mg p.o. b.i.d., Lisinopril 10 mg
  p.o. q.day, Lasix 40 mg p.o. q.day, aspirin 325
  mg p.o. q.day, albuterol 2.5 mg nebulizer q.4h.
  as needed for shortness of breath, Atrovent 0.5
  mg nebulizer q.4h. p.r.n.
• PAST MEDICAL HISTORY CHF for five years.
  Hypertension and hepatitis C. Substance abuse.

40
Priceless InformationSocial HistoryPage 3

• ALLERGIES NO KNOWN DRUG ALLERGIES.
• FAMILY HISTORY The patient is not aware of his
  family history as they all live in New York.
• SOCIAL HISTORY The patient lives with his
  girlfriend and children. The patient is
  unemployed. A 20 pack per day smoking history.
  Does have some alcohol use, recent tobacco use
  and cocaine use. Last cocaine use was three days
  prior to admission.

41
Priceless InformationDigestion of Your Workup

• DISCHARGE DIAGNOSES
• 1. Syncope, possibly due to volume depletion.
• 2. Hypertension.
• CONSULTATIONS
• 1. Cardiology.
• 2. Neurology.
• HISTORY OF PRESENT ILLNESS This is an
  80-year-old African American female who presented
  with fainting and falling down to the ground.
  Apparently she did fall this morning. She
  suddenly fell down and EMS brought her to the
  hospital.
• She has lost consciousness and she is not aware
  of any preceding symptoms. She had no seizure,
  no chest pain, no palpitations, denies dizziness,
  no loss of bowel or bladder control, no visual
  change and no weakness in her limbs. There was no
  confusion after the episode.

42
Priceless InformationDigestion of Your Workup

• PAST MEDICAL HISTORY
• 1. Hypertension for 15 years.
• 2. No diabetes noted in the past.
• 3. No history of heart disease.
• 4. No history of CVA.
• 5. No previous history of seizure.
• MEDICATIONS
• 1. Nifedipine 30 mg orally every day.
• 2. Librium as needed.
• FAMILY HISTORY She is not aware of any
  illnesses of family.
• SOCIAL HISTORY She smokes a half a pack per day
  since teenager, denies alcohol and intravenous
  drugs. Home Situation?
• PHYSICAL EXAMINATION VITAL SIGNS Blood
  pressure 139/18 erect and 149/18 supine. Pulse
  89 erect and 80 supine. Temperature 98.1.
  Respirations 20.

43
Priceless InformationDigestion of Your Workup

• GENERAL She is an 80-year-old elderly female.
  She is not in any distress. HEENT Extraocular
  movements are intact, anicteric sclerae. Neck
  soft. There is no JVD. She had ecchymosis on
  the face and swollen lips. HEART Regular rate
  and rhythm, S1, S2 were heard, no murmur or
  gallop. LUNGS Clear to auscultation
  bilaterally. No palpable lymph nodes. ABDOMEN
  Soft, nontender, no distention, positive bowel
  sounds. EXTREMITIES No pedal edema.
  NEUROLOGICAL Alert, oriented x3, no focal
  neurologic deficit???
• EKG shows normal sinus rhythm, left ventricular
  hypertrophy by voltage criteria.
• Chest x-ray showed chronic mild pulmonary
  disease.
• CT of the head showed no acute intracerebral
  hemorrhage, midline shift or mass effect. It did
  show chronic microvascular ischemic changes and
  old lacunar infarcts.

44
Priceless InformationDigestion of Your Workup

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

45
Priceless InformationDigestion of Your Workup
DIGEST HERE

• HOSPITAL COURSE She was admitted for syncope.
  Cardiology and neurology were consulted and
  cardiology suggested that syncope not related to
  any cardiovascular problem. A 2-D echo was
  performed and it showed ejection fraction of 65,
  normal left ventricular function and no abnormal
  finding. Her serial EKGs showed normal sinus
  rhythm. Troponin was negative three times.
  Neurology service suggested that syncope was not
  related to any neurogenic problem. The patient
  received gentle IV hydration. She was stabilized
  and discharged on July 18, 2005 with her home
  medications, Nifedipine for her blood pressure 30
  mg orally every day.
• The patient was instructed to return to her
  outpatient clinic follow up and instructions plus
  diet was given.
• CONDITION ON DISCHARGE The patient was
  discharged in stable condition.
• Or youre asking the next team to do that work.

46
Precision

• DATE OF ADMISSION 07/07/2005
• DATE OF DISCHARGE 07/08/2005
• ATTENDING PHYSICIAN RANDY A LIEBERMAN,
  MD
• DIAGNOSES 1.
  Chronic heart failure.
• 
  2. Hypertension.
• PROCEDURES ICD generator
  change.
• HISTORY OF PRESENT ILLNESS The patient is a
  68-year-old African-American male with a history
  of pulseless ventricular fibrillation, ICD
  placement in 1986, And he was admitted for a
  generator change at this time. The patient
  denies any syncope, chest pain, shortness of
  breath or palpitations. He has no complaints at
  the present time.
• ALLERGIES No known drug allergies.
• PAST SURGICAL HISTORY Colectomy because of
  colon cancer

47
Precision

• SOCIAL HISTORY The patient quit smoking in
  2005.
• ASSESSMENT The patient was admitted to the EP
  department. At the time of
• admission he had no complaints.
• PHYSICAL EXAMINATION The patient was in no
  acute distress. Cardiovascular Clear heart
  tones. Regular rhythm. Extremities No edema.
  Lungs Breathing is audible bilaterally. Neuro
  The patient is alert and oriented x3. No focal
  deficits.
• HOSPITAL COURSE The procedure was performed on
  July 7 at 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.

48
Precision

• His medications include Tylenol No. 3 one to two
  pills p.o. q.4h. for pain control, morphine 1 to
  2 mg IV push q.2h. for pain control, Coreg 25 mg
  p.o. b.i.d., lisinopril 40 mg p.o. daily, Norvasc
  10 mg p.o. daily, Lasix 40 mg p.o. daily, Zocor
  20 mg p.o. daily.
• A lab test the next morning, July 8, showed a
  sodium of 139, potassium 3.7, chloride 108,
  bicarbonate 26, BUN 11, creatinine 0.9, glucose
  75. White count 9.7, hemoglobin 129, hematocrit
  39.1, platelets 210. There was a small hematoma
  formation at the ICD placement site. This was
  followed by the EP technician.
• DISPOSITION The patient was discharged home on
  July 8, 2005 with follow up with Dr. Randy
  Lieberman in the EP Clinic. The appointment is
  scheduled for July 22, 2005 at 830 a.m. The
  phone number for contact is 313-745-2626.
• CONDITION ON DISCHARGE Stable to home.

49
Precision

• .
• This dictation was concise but not THOROUGH
• Review of the medical record revealed
• CASHD with 40 mid LAD 100 distal LAD with
  patent grafts
• An akinetic inferior wall
• EF 10 without LVH
• h/o Atrial Fibrillation
• PUD
• What were his discharge medications??

50
Proper OrganizationComplete Precise Data on
the First Page

• CHIEF COMPLAINT Altered Mental Status, per
  nursing home.
• PRINCIPLE DIAGNOSIS Delerium due to UTI.
• DISCHARGE DIAGNOSES
• 1. Multi-infarct
  Dementia
• 2. Hepatitis.
• 3. Diabetes type
  2.
• 4. Incontinence.
• 5. Prostate
  cancer.
• CONSULTS Consults were to orthopaedic surgery,
  radiation oncology, psychiatry, occupational
  therapy, physical therapy, neurology, urology,
  and social work.

51
Improper 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.

52
Improper Organization Problem List Scattered
Throughout Text

• PAST MEDICAL HISTORY Hypertension, CHF, ARF,
  anemia, pancreatitis, alcohol abuse, arthritis.
• PAST SURGICAL HISTORY Mitral valve replacement
  (porcine), motor vehicle accident with loss of
  consciousness in 2001
• SOCIAL HISTORY Unemployed, lives alone. Her
  son helps her out. She quit smoking and drinking
  3 weeks ago. She smoked a half a pack a day for
  about 36 years. She denied any drug use. She
  has Medicaid insurance.
• DIAGNOSTIC STUDIES
• --Echocardiogram in March 2005, showed an
  ejection fraction of 45, normal LV size with
  mild LV hypertrophy and a bioprosthetic valve.
• --CT of the abdomen showed free pelvic fluid,
  moderate with pleural
• effusion and no bowel obstruction.

53
Improper FormSymptom Listed as Diagnosis

• HOSPITAL COURSE The patient was admitted with
  the following problems
• PROBLEM NUMBER 1. Congestive heart failure
  exacerbation.
• PROBLEM NUMBER 2. Abdominal pain. One of the
  main complaints that the patient came in with was
  abdominal pain, and the first impression was due
  to liver congestion secondary to CHF. The
  patient showed some improvement on the first
  couple of days after admission, but again, she
  started to complain of abdominal pain. Then,
  surgery was consulted, and after surgery saw her,
  they decided that the problem was not a surgical
  problem. Finally, endoscopy was done, and
  endoscopy showed diffuse gastritis and a little
  bit deformed bulb, and she was ordered a proton
  pump inhibitors. Endoscopy was ordered after GI
  was consulted. Ultrasound of the gallbladder no
  stones in the gallbladder, but it showed diffuse
  fatty infiltration of the liver 2 right-sided
  pleural effusions.

54
Improper FormDiagnosis Hidden in Text

• HOSPITAL COURSE The patient was admitted with
  the following problems
• PROBLEM NUMBER 1. Congestive heart failure
  exacerbation.
• PROBLEM NUMBER 2. Abdominal pain. One of the
  main complaints that the patient came in with was
  abdominal pain, and the first impression was due
  to liver congestion secondary to CHF. The
  patient showed some improvement on the first
  couple of days after admission, but again, she
  started to complain of abdominal pain. Then,
  surgery was consulted, and after surgery saw her,
  they decided that the problem was not a surgical
  problem. Finally, endoscopy was done, and
  endoscopy showed diffuse gastritis and a little
  bit deformed bulb, and she was ordered a proton
  pump inhibitors. Endoscopy was ordered after GI
  was consulted. Ultrasound of the gallbladder no
  stones in the gallbladder, but it showed diffuse
  fatty infiltration of the liver 2 right-sided
  pleural effusions.

55
The Data

• Include
• Concise information.
• Pertinent labs
• Priceless Information
• Medication List
• Follow-up Instructions
• Psych/Cognitive Disorders
• Baseline Exams

• Exclude
• Repetition
• Normal Labs
• Prose
• Inaccurate Information
• From the Patient
• From the Chart

56

• If you dont know your destination
• every road will take you there

57
The Destination

• Organize yourself
• Index Card with static information
• Name
• Numbered Problem List
• Cognitive Deficits
• Psychiatric Diagnoses
• Pertinent Social History
• Family Contacts
• Medications
• PCP Name Number

58
Proper 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

59
Proper 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

60
Proper 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.

61
Proper 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.

62
Proper 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.

63
Proper 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

64
JCAHO National Patient Safety Goal 8

• "Accurately and completely reconcile medications
  across the continuum of care
• Goal Reduce Adverse Drug Events
• Compile the admission medication list and
  comparing those medications with what is being
  prescribed.
• The DMC will communicate a complete medication
  list to whoever is the next health care provider
  in charge.

65
When to Dictate

• The same day the patient is
• Discharged Home
• Leaves AMA
• Leaves your service after 7 days
• ICU transfers
• Off service
• Discharged to another facility
• RIM
• NH
• Another DMC Hospital

66
Who Should Dictate?

• A physician who knows the patients hospital
  course

67
Exit To Your Right
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