Transcript Document

It’s Midnight.
You’re on call at DRH
You have 3 patients waiting in
the modules…
How hard do you want to work for your
information?
Appropriate Dictation Form
and Content
Clifford A Kaye M.D.
Summer Lecture Series 2006
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.
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.
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 35 days prior to admission. No IV drug use. No alcohol use. No smoking of
tobacco. The patient lives alone in an apartment.
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.
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.
Goals & Objectives:
Teach the utility of discharge dictations as a
means to communicate clear & concise
clinical data.
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–
–
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What data to include and exclude.
How to organize the data.
When to dictate.
Who should dictate.
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
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
Proper Form
The Body of a Dictation
• Surgical History
• Social History including contact persons and
numbers
• Pertinent Exam
– Don’t bury pertinent findings in a lengthy normal
exam.
• Pertinent Studies
– Labs
– Gram Stains
– Radiography
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.
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.
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
patient’s CHF.
Improper Form
• Repetition
• Misleading Information
• Unnecessary Information
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:
1. Central respiratory failure
2. Pneumonia, methicillin-resistant Staphylococcus aureus sepsis. #1
3. __________ collapse.
4. Anemia.
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
#2
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.
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
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+.
****
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
#4
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 …
Repetition
HOSPITAL COURSE: (cont)
4. 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[…]
5. He was on gastrointestinal and deep venous thrombosis
prophylaxis of intravenous Protonix and subcutaneous
heparin.
6. 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 11:00 p.m. on October 09, 2005. The
patient was off the ventilator and at 11:27 p.m., the patient
went into cardiorespiratory arrest and expired. The patient
was declared dead around 11:30 p.m., his pupils were
fixed...
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.
Misleading Information
Hospital course:
1-Respiratory:
Right Upper lung infiltrate-questionable mass- per imaging studiesChest 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.
Misleading Information
Hospital course:
1-Respiratory:
Right Upper lung infiltrate-questionable mass- per imaging studiesChest 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
FOB bronchial epithelium with minimal atypia, consistent with reactive
Resultschanges. 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.
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.
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
Prose
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
….
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.
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.
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 AccuChek was 273. The patient has been scheduled in my clinic in the
GMAP Building for 1p.m. on Monday, 08/22/2005.
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 AccuChek was 273. The patient has been scheduled in my clinic in the
GMAP Building for 1p.m. on Monday, 08/22/2005.
Proper Form
• Abnormal Labs Only
• Priceless Information Regarding
– Cognitive Disorders
– Personality Disorders
– Baseline Function
– Social History
• DIGESTION of your workup
Pertinent Labs
DATE OF ADMISSION:
DATE OF DISCHARGE:
FINAL DIAGNOSIS:
10/27/2005
10/31/2005
Acute lobar nephronia/ early renal abscess.
HISTORY OF PRESENT ILLNESS: The patient is a 27-year-old AfricanAmerican 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.
Priceless Information
Cognitive 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. NEUROLOGIC:The
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.
Priceless Information
Cognitive 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. NEUROLOGIC:The
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.
Priceless Information
Social History
Page 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.
Priceless Information
Social History
Page 2
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old AfricanAmerican 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.
Priceless Information
Social History
Page 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.
Priceless Information
Digestion 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.
Priceless Information
Digestion 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.
Priceless Information
Digestion 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.
Priceless Information
Digestion 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.
Priceless Information
Digestion 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.
DIGEST HERE
Or you’re asking the next team to do that work.
Precision
DATE OF ADMISSION:
DATE OF DISCHARGE:
ATTENDING PHYSICIAN:
DIAGNOSES:
PROCEDURES:
07/07/2005
07/08/2005
RANDY A LIEBERMAN, MD
1. Chronic heart failure.
2. Hypertension.
ICD generator change.
HISTORY OF PRESENT ILLNESS: The patient is a 68-year-old AfricanAmerican 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
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 5:30
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 9:15 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.
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 8:30 a.m. The phone
number for contact is 313-745-2626.
CONDITION ON DISCHARGE: Stable to home.
Precision
.
This dictation was concise but not THOROUGH
Review of the medical record revealed:
1)
CASHD with 40% mid LAD 100% distal LAD with patent grafts
2)
An akinetic inferior wall
3)
EF 10% without LVH
4)
h/o Atrial Fibrillation
5)
PUD
6)
What were his discharge medications??
Proper Organization
Complete & 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.
Improper Organization
Incomplete 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 AfricanAmerican female who presented with upper abdominal squeezingtype 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….
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.
Improper Form
Symptom 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.
Improper Form
Diagnosis 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.
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
“If you don’t know
your destination …
… every road will
take you there”
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
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
Proper Form
The Body of a Dictation
• Family & Surgical Histories
• Social History including contact persons and
numbers
• Pertinent Exam
– Don’t drown pertinent findings in a normal exam.
• Pertinent Studies
– Labs
– Gram Stains
– Radiography
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.
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 patient’s CHF.
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
patient’s CHF.
Proper Form
The Conclusion
•
•
Condition at Discharge
Discharge Medication List
–
•
Discharge Instruction
–
–
•
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
Diet
Activity
Follow-up Appointments
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.
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
Who Should Dictate?
A physician who knows the patient’s hospital
course
Exit To Your Right