Clinical Documentation

1. Clinical Documentation Amish A Dangodara, MD, FACP Professor of Medicine Hospitalist Program University of California, Irvine School of Medicine 07.11.14

2. Need 2 Volunteers:R1 & R3

3. Clinical Documentation • Chief Complaint • HPI: 4+ elements of chief complaint • Past Hx: 3/3 • PMHx • Medical, Surgical, Psych, OB, etc. • Allergies, Medications • FHx • SHx • ROS: 9+ systems • Exam: 8+ systems or 2 detailed systems • Data: 2+ elements • Assessment: acute, active, unstable • Plan

4. High BP, 1985 High cholesterol, 1989 Diabetes, 1991 Pancreatitis, 1994 Gall bladder surgery, 1994 Liver failure & sepsis, 1994 Tracheostomy & G-tube, 1994, removed 1995 Blood clot in lung, 1994 Fluid in lung, 2005 Ovarian cancer, 2005, surgery 2006, chemotherapy 2005-2007 Atenolol 100 mg at night Fosinopril 20 mg per day, twice a day Lasix 20 mg per day Glyburide 15 mg per day, 2 in morning, 1 at night Lipitor 40 mg at night Multivitamin 1 daily Calcium/Vitamin D twice a day Vicodin extra 1, 4-5 times a day Iron 325 mg 1 - 2 times a day Case Ms. Anne Gina Pektoras is a 56 year old Greek woman who presents with a chief complaint of abdominal pain and shows you the following list:

5. Case The ED nurse hands you the following information: BP 98/56, P 112, RR 16, T 37.6, Wt 82 Kg Na 146, K 2.9, Cl 114, HCO3 32, BUN 26, Cr 1.4, glucose 54 WBC 6400, Hgb 14.8, Hct 46%, Platelet 273,000 Albumin 3.8, Alk Phos 68, TBil 1.2, AST 24, ALT 22 INR 0.98, PTT 32, CK 427, MB 6.3, MBI 1.5, troponin <0.03

6. Initial Differential Dx What is the most likely cause of abdominal pain? • Cardiac • Gastric/Liver/Pancreas • Vascular • Neurological • Muscular • Infectious • Metabolic/Endocrine • Intestinal • Neoplastic • Other

7. Obtain and Review the H&P

8. Exam Vitals: BP 98/56, P 112, RR 16, T 37.6, Wt 82 Kg HEENT: dry oral mucosa Abdomen: slightly distended, old midline scar from pelvic surgery, old scars from prior G-tube and colostomy that was reversed, tympanic to percussion, no HSM, no ascites or other stigmata of chronic liver disease, diffusely tender, but more in LLQ, no peritoneal signs, slightly hyperactive high pitched bowel sounds Pelvic: blind vaginal cuff without discharge or tenderness Rectal: normal tone, non-tender, no blood Extremities: tachycardic pulses, thready, poor skin turgor Rest of exam is normal

9. Assessment What is the most likely cause of abdominal pain? • Cardiac • Gastric/Liver/Pancreas • Vascular • Neurological • Muscular • Infectious • Metabolic/Endocrine • Intestinal • Neoplastic • Other

10. Plan What initial test(s) will you order? • Additional cardiac enzymes • AAS • CT Abdomen/Pelvis • Pancreatic enzymes • Abdominal U/S • Blood and urine cultures • ABG • CT Chest Angiography • Other

12. H & P HPI: This is a normally independent 56 year old woman who lives alone and presents with 7-9/10 severity, intermittent, achy, pressure-like, sometimes sharp, left-sided abdominal pain, lasting hours to days that began 2 months ago, initially with a frequency 1-2 times per week, and now progressing to nearly daily occurrence for the past week, associated with 1 week of constipation and nausea but without emesis or distention. The pain is exacerbated by eating solids more than liquids but unaffected by positional changes of the body and does not radiate anywhere, but is somewhat improved with eructation and flatus, as well as Vicodin which reduces severity to 3/10. She has reduced dietary intake for 2 days associated with dizziness and weakness, as well as clouded thinking and sweating. She denies alcohol use, hematemesis, BRBPR, or diarrhea. PMHx includes pancreatitis in 1994 and Ovarian cancer in 2005.

13. What is Assessment now? What is the most likely cause of abdominal pain? • Cardiac • Gastric/Liver/Pancreas • Vascular • Neurological • Muscular • Infectious • Metabolic/Endocrine • Intestinal • Neoplastic • Other

14. Evaluate H&P

15. Summary: HPI HPI: 7 elements of the chief complaint • Location • Quality • Chronology/Duration • Severity/Intensity • Associated Symptoms • Aggravating or Alleviating factors • Impact or intervention • Symptoms associated with differential diagnoses for chief complaint, whether positive or negative (ROS pertinent to chief complaint) • Important past history or prior work-up that relates to chief complaint • Avoid PMHx in first sentence unless VERY pertinent

16. Summary: Past History Past Medical History: • Explain all medications with associated Dx • Approximate onset and current status of problem • Describe specifics if known (complications, how Dx made) • Describe laterality (right shoulder pain, etc) or location (left arm DVT, etc) • Determine nature of allergic reaction, if known • Determine how medications are taken Family History: • Focus on genetically transmitted conditions, infectious exposures, cause of death Social History: • Focus on living situation, relationship, employment, independence, habits, environmental exposures

17. Summary: ROS and Exam ROS: • List by system and label the system • Do not repeat or contradict what was in HPI (copy/paste or templated ROS that is not carefully edited) Exam: • List by system and label the system • Findings should reflect current exam (avoid copy/paste or templated exam that does not apply to patient) • Include pertinent negatives for what you were looking for as a result of presenting problem (rather than templated “standard” negative findings) • List only what you actually examined and only examine what was clinically indicated for patient’s current status (avoid copy/paste or unedited templates)

18. Summary: Data Data: • List findings pertinent to indication for why test was ordered (avoid copy/pasting entire reports or impressions) • List “unexpected” findings only if they are clinically impactful • Trend results if trending reveals important nuance that may not be easily appreciated based on single value • Indicate if you personally interpreted the data or coordinated interpretation with another specialist

19. Summary: Assessment Assessment: • Commit to a Dx or symptom followed by differential Dx, even if not certain (probable, possible, likely, or unlikely are ok) • Avoid a summary of findings without associated Dx • Avoid “rule out” terminology, “FEN,” or “prophylaxis”; indicate risk or Dx • Indicate ICD-10 components: • Dx or symptom followed by differential Dx and likelihood • Type or Stage • Acuity or severity • Location and/or laterality • Timing (present on admission, initial presentation, subsequent eval) • Etiology (pathogen) • Complication of Dx or associated co-morbidity

20. Summary: Plan Plan: • Each plan should have corresponding assessment(s) • Provide brief rationale for plan • Should logically follow from assessment • Include preventive measures on initial plan

21. Questions?