Papers, Prescriptions and Presentations

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Papers, Prescriptions and Presentations

• Deborah D. Nelson, MD.
• Valerie P. Jameson, MD.
• University of Tennessee

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So . . . You want to get an A.
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Its communication, stupid!

• Evaluators can only judge what they can
  experience.
• what they hear you say
• what they read that you write

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Today

• Introduction to the medical chart
• Progress note
• Oral presentations
• Writing orders
• Prescription writing
• Introduction to coding

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The Medical Chart

• ED or hospital transfer notes
• Demographic sheet
• Physician orders
• Charts (vital signs, weights, Is Os)
• Consults
• Medication record
• Nurses notes
• History and Physical
• Progress notes
• Labs, radiology, operative reports
• Social worker, PT, OT and respiratory notes
• Miscellaneous

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What is the purpose of the Medical Record?

• In the past a reminder for the physician
• A way of organizing thoughts
• Medicaid/Medicare government regulation
• Means of justifying billing
• Means of legal defense and offense
• For medical students -

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For medical students,

• the medical record is a way of communicating
  their knowledge, understanding and abilities to
  the residents and attendings.

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The Progress Note

• Date and Time
• Basic Info
• S- subjective
• O- objective
• A- assessment
• P- plan
• Signature

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Date and Time

• Date and Time every note, every time

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Basic Info

• Writers identification
• Patient identification age, race, gender
• Main problem
• Hospital day number
• calendar day
• Antibiotic/Medication day number
• 24 hours periods

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Subjective

• Patient or caregiver complaints
• BMs, flatulence, dysuria, bleeding, nausea
• Are you better or worse?
• If no patient or caregiver then no S
• Nursing notes are considered medical facts, and
  therefore are not included in subjective data.

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Objective

• Cited nurses notes
• General description
• Vital signs, weights, Is Os
• Physical exam
• New laboratory and procedure results

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Assessment

• Interpret all above data
• No comment assumes data is acceptable?
• Define the patients problem(s)
• Address both acute and pertinent chronic
  problems.
• Nature of the problem
• Status of the problem (improved/worsened?)
• Give differential diagnosis for new problem(s)
• Defend your diagnosis and management
• This is where your attending will really see what
  you are thinking! (Or, not.)

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Plan

• New or change of orders
• Plans for current management
• Diagnostic
• Therapeutic
• Patient education
• Contingency plans
• Ultimate discharge planning
• Record instructions given to patients

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SOAP Difficulties

• SOAP notes are fine for uncomplicated patients,
  but are unwieldy for more than one problem.
• For complicated patients, use system or problem
  oriented note.
• Each problem has its own assessment and plan.
• Facilitates oral presentations significantly.
• Lends itself to producing a note that has design
  but no substance.
• Dont get hung up in the mechanics.

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Problem Oriented Note
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Signature

• Legible
• Print name under cryptic signature
• Multiple page notes - signature on every page.

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Bah gjpemal

• It doesnt matter how brilliant you are if they
  cant read your handwriting!
• Cross out errors with a single line never
  obliterate. Then, initial and date.
• If your signature is illegible print your name.
• Never give the impression of tampering.
• Avoid using abbreviations, but if you do, use
  only those that are approved by your institution.

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Its communication, stupid!

• Legible!
• Concise but complete
• Support your diagnosis and plan
• Sacrifice detail for clarity
• Too messy no one will read it.
• Too wordy no one will read it.
• Too redundant no one will read it.

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Pearls

• Document every encounter every order should be
  supported by a note.
• Every patient gets a note daily, but not every
  problem needs be addressed daily.
• Cant just write Stable.
• Record pertinent negatives.
• WNL means We never looked.
• Different people have different philosophies
• Do what your attending wants!
• Be Flexible!

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Oysters

• In the courtroom, the medical record is a
  witness that never dies.
• Truth is not what really happened, it is what is
  in the medical record.
• Never remove notes from a chart.
• Notes go in the chart at the time they are
  written.
• Once a note is signed, it cannot be changed.
• Never add clarifying or editorial comments later.
• No chart wars or disparaging comments about
  patients!
• Never plagiarize!

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The Oral Presentation

• First off
• Figure out why you are presenting this patient in
  the first place

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Is this a . . .

• Formal Presentation?
• Grand Rounds, MM, etc.
• Initial vs. progress presentation?
• With or without PMHx, social, etc.
• Informal work rounds presentation?
• Get done and get out of Dodge

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What is your attending doing while you present?

• Trying to determine patient problems and needs.
• Evaluating team cohesiveness and function- i.e.,
  the ability of the residents to lead and teach.
• Thinking about teaching points to be made.
• Evaluating your ability to . . .

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What the attending learns about you when you
present-

• Gather data and assimilate
• Analyze and prioritize
• Organize
• Show proof of your level of medical knowledge
• Clinically apply that knowledge base
• Communicate effectively

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So much to do, so little time!

• Be Prepared!
• Engage the listener
• Tell a story
• Be concise but complete- 3-15 min max
• Only pertinent positives and negatives
• However, must be familiar with all data
• Sacrifice detail for clarity
• Chronology
• Chronology of HPI vs hospitalization
• Eye contact minimal prompters
• Emphasize important points
• Sell your diagnosis and management

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Tips

• Remind everyone who youre talking about
• Avoid redundancy
• Practice pronunciations
• Avoid abbreviations
• Never confabulate! Say I dont know, when you
  dont know.

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Writing Orders

• ADC Vaan Dimsel

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• Date and Time
• A Admit
• D Diagnosis
• C Condition
• V Vital signs
• A Allergies
• A Activity
• N Nursing procedure
• D Diet
• I Is Os
• M Medications
• S Symptomatic drugs
• E Extra
• L Labs
• Signature

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Orders, etc.

• Date and Time
• Legible!
• No felt tip or fountain pens
• Always check the MAR
• Look up every medication your patients are
  taking.
• What does stable mean?
• Signature
• Avoid phone orders
• Support all orders with notes
• Dont use abbreviations

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• tid means at breakfast, lunch and dinner
• q8h means every 8 hours
• qid means 6am,10am,2pm,6pm
• q6h means 6am,12pm,6pm,12am

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Abbreviations

• Use leading zeros 0.5mg instead of .5mg
• Dont use trailing zeros 5mg not 5.0mg
• Dont use u- write out Units
• Dont use d use dose or day
• Dont use mcg- write out micrograms

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Infant Dies of Overdose Doctor settles for
millions
Commercial Appeal

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  she meant to write dfhsdfd fgt utey grsag erg y
  th gr y yw a ytr use rt aert a
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  akjf a a fa asfter r werg dfga fsd
  dfhsdfdfgtutey grsag erg y thrw a gr y yw a ytr
  usertaert a agaert ataergansasdf asdhf adjf

• Memphis, TN 9 month old baby girl died of an
  overdose of morphine because a physician wrote
  .5mg which was transcribed as 5mg . It wasnt
  until later that night when the infant was
  discovered blue that the error was discovered.
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  fdf sf flsdjhflkhg tlkth aldgh algkjhag lk4ht
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  hrlhwelkehf

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Writing Prescriptions

• Patient name spelling is important
• Date
• Patient address only for controlled meds
• Rx Latin for recipe- Medicine name
• Strength mg/ml, mg per tablet, capsule
• Sig.- Latin for Signa meaning label-
  Instructions to patients in taking the
  medication.
• Disp make a mark after the number to prevent
  tampering.
• Signature sign over Dispense as Written or
  Substitution Allowed Always print your name as
  well.
• DEA number only required for controlled
  substances
• Number of refills - prn

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To write a Rx, you need to know

• About the drug you want to use
• Efficacy, cost, side effect, drug interactions
• Controlled or uncontrolled
• Dose
• Duration
• Strength and size available
• Patient allergies
• Insurance status - formulary

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Controlled Substances

• No scratch outs
• DEA number required
• No misspelling
• Write out numbers- 20 is twenty
• Mark after number
• Frequently special prescription pad only

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Write a prescription

• Dont write scripts for relatives, friends or
  yourself.
• Limit amounts frequently abused drugs.
• Dont leave scripts lying around.

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Introduction To Medical Coding

• Do You Want To Be Paid?
• Way to communicate with third party payors
• Codes represent diagnoses, physician services and
  procedures, and medical services and supplies
• Superbill

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Whats and Whys and Hows

• CPT codes
• What you did and
• How you did it
• Current Procedural Terminology
• Services
• Procedures

• ICD-9 codes
• Why you did it and
• What you found
• International Classification of Diseases 9th
  revision
• Symptoms / Signs
• Diagnoses
• Causitive agent

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Develop Good Habits Now!

• Documentation is key
• Government regulation HCFA
• Fraud and abuse charges
• Reality is defined only by what is written in the
  medical record

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Keys to Success

• See it yourself.
• Assume you are not going to sleep on call.
• Common things occur commonly- but think about
  deadly zebras, too.
• Be a lumper, not a splitter.
• If someone gives you a job do it! Dont make
  excuses.
• Perform full HPs- you cant see too many
  normals.
• Take every opportunity to see interesting
  physical findings.
• Make a point to never be surprised by a lab
  result.
• Treat the patient, not the lab.
• Never trust a monitor.

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Wait . . .theres more!

• Theres no person with whom you come in contact
  who doesnt need respect notice thats not
  deserve.
• Document, document, document!
• Say, I dont know daily, then find the answer
  yourself.
• Dont be proud.
• Never go down alone! Get help.
• Abandon a diagnosis that doesnt fit.
• Question authority, but respect experience.
• Knowledge is power!
• Ownership!