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Compliments of Eric Steen. Notes on Notes(Geared toward podiatry students, but good info for all) Lots of stuff can be written about notes. Make them concise, and easy to follow. One way to do that is to follow a familiar format. If you use the same format all the time, it will be easy to remember what you need to address next. If you use the same format that others do, it will be easy for them to read your notes, or for you to follow their notes. Not all follow the exact same format, but the variations are close enough that it is fairly easy to read, and remember. Some of the information here may seem repetitive. In some cases different variations are given for comparison. Note that the differences are minor. Which one you use doesn’t really matter, as long as you cover all the information necessary. They will also seem repetitive, because the information will be written out with comments and may be shown a second or third time in a more condensed version. The comments do not mean that all of that information needs to be included every time, but rather to show what might be included. History CC: “In the Patient’s own words” HPI: NLDOCAT or OPQRSTA Pertinent ROS:+/- of involved systems. PMH: Allergies: Drugs/Food/environmental – note reactions Meds: Names/Dosage/Freq + OTC, BC, herbals General Health: Childhood illness: MMR, DPT,chickenpox, scarlet fever, etc Major Adult Illness: BIG 8 + Infx (TB, Hep) & hospitalization Serious injuries/disabilities: Transfusions: PSH: What, when, where, outcome. Soc Hx:Occupation: Partners/living arrangements: Children: (anyone at home with similar symptoms?) Tobacco: EtOH: Illicit drugs: VD hx: Immunizations: “usual childhood” + Tetanus,Hep B, Pneumo,Flu Recent travel: Military Service: Diet: Typical + use of salt/sugar, caffeine Fam Hx: Parents: Alive/Deceased (cause), age, chronic med probs, The Big 8 Children: Health Siblings: Health Review of Systems ROS: To help you focus your exam, consider a review of all other systems. This history may be exhaustive or extremely short depending on the patient and the nature of the problem. General: First Impression. Nutritional status, weight gain/loss, weakness, fatigue, hydration status & overall condition? Skin: Changes in skin/nail/hair texture, appearance and color. Rashes, itching, lumps or infection? Cellulitis, Lymphangitis, lymphadenopathy? Head: Loss of consciousness? Lightheaded, vertigo, headaches, symmetry, Hx of Injury, PMH, sinus pain? Visual disturbance? Ears: Acoustic trauma, hearing loss, tinnitus, drainage, pain, infection, discharge, vertigo. Hearing aids? Last Exam? Eyes: Visual changes, diplopia, epiphora, pain, discharge, injection, light halos, trauma, photophobia, glaucoma, cataracts, last eye exam? Iritis, visual acuity, and Glasses/contacts? Nose/Sinuses: Olfactory changes, stuffiness, drainage, itching, obstruction, hx of trauma, hay fever, nosebleeds, sinus problems. Throat/Mouth: Hoarseness, dysphagia, enlarged tonsils, bleeding gums, sores, leukoplakia, teeth condition, caries, tongue changes, dry mouth, hx of sore throat? Neck: Goiter, pain, masses, nodules, adenopathy, thyroid problems, stiffness, creptitus? Hx of Injury? Respiratory: Cough, dyspnea, pleurisy, sputum (amt, type, color), asthma, bronchitis, COPD, emphysema, effusion, TB, last CXR? Coccidiomycosis, Histoplasmosis and smoking history? Cardiac: HTN, hyperlipidemia, rheumatic fever, murmurs, chest pain/discomfort, orthopnea, dyspnea, edema, last ekg/stress test? CHF, pericarditis. Hx of surgeries/procedures/monitors. Peripheral vascular: Nocturnal pain, claudication, varicose veins, thrombophlebitis, leg cramps? CHF? Venous insuffieciency? DVT? Gastrointestinal: Heartburn, dsyphagia, appetite, indigestion, belching, flatulence, hematemesis, stool changes, hemechezia, melena, diarrhea, constipation, nausea, regurgitation, vomiting? Hx of gallbladder, liver, pancreatic disease, PUD? Genital (male) Hernias, sores, lesions, penile discharge, pain , testicular/mass discomfort, scrotal mass/discomfort? hx of STD's. Sexual hx, function, problems? Genital (female): Birth control, sexual hx/function, STD's, itching, sores, discharge, dyspareunia, last pap/pelvic exam? Menarche, menopause, LMP, GPA, menstrual regularity, frequency, duration, amt? Dys/amenorrhea, metromenorrhea and PMS, Urinary: Dysuria, polyuria, frequency, stones, pattern change, incontinence, nocturia, STD, hesitancy, dribbling, hematuria, infections? Flank discomfort? Hematologic: Anticoagulants, bleeding, bruising, anemias, petechia, hx of transfusions, sickle cell, thalassemias, G6PD? Endocrine: Thyroid, adrenal, hormonal. Heat/cold intolerance, edema, hirsutism, sweating, excessive thirst, hunger, polyuria, pigment changes? Psychiatric: Anxiety, mood swings, mania, depression, memory loss, insomnia, suicidal ideations, delusions, hallucinations? Musculoskeletal: Myalgia, stiffness, gout, arthritis, backache. Hx of swelling, pain, erythema, tenderness, decreased ROM? Hx of trauma, overuse. Neurologic: Syncope, vertigo, seizures, blackouts, parasthesias, paralysis, tremors, weakness, involuntary movements, equilibrium, LOC. Other Problems and past medical history:
Lower Extremity PE Lower Limb PE: VDON Vascular Pulses DP/PT (1-2/4 normal) SPVPFT Edema (Pitting?) 0-3+ Hair growth Skin Temp (cool to warm distal to proximal) Derm Skin (turgor, texture, temp) Any lesions – (open, maceration, ulcers) describe Nails Calluses (location, type - HD, HM, IPK) Ortho Strength (0-none, 5- normal) ROM Deformity (bunion, hammertoes) Biomechanics Neuro Protective Threshold (Semmes Weinstein) Intact/not, where it stops DTR (0 absent, 2+ normal, 4+ hyperactive) Patellar (L2-4) Achilles (L5-S2) Vibratory sensation Proprioception Other Labs X-rays
The SOAP Format Lots of different types of notes can be made to fit the SOAP format. You’ll want to be very familiar with this one. It can be used for Outpatient notes in the clinic. It works just as well for progress notes on inpatients. It can be used for Pre-Op notes, but there may be better formats to help remember all the additional information needed for those.
Subjective: This is where you put the patients story. Often the chief complaint is written in quotations using the patients own words. This may be very brief. Or it can be expanded to include the history of the present illness. NLDOCAT can be used here. Or it may be expanded to include The entire history. All of this material is subjective since it is what the patient is telling you. Depending on CC, consider everything, and document the essential points. Pick your questions well. If you don’t ask, they might not tell. Objective: This is where the data goes. Your physical exam goes here, as well as any labs, x-ray reposts or other ancillary studies. Many items this may be a simple lower extremity physical exam, which usually fits pretty well in a VDON format (Vascular, Derm, Ortho, Neuro). Again, this is only one way to organize the information. Any way is OK, as long as all the needed stuff gets there. Assessment This part is usually fairly short. This is your Diagnosis. It may be written out as a numbered list. You may also include some other important bits. You might include that they are diabetic, or neuropathic, if the current problem is an ulcer that is related to those conditions. If you do not have a definitive diagnosis, the assessment might be R/O osteomyelitis. Plan: Include here anything that was done or will be done. Treatments given in the office. Prescriptions given. Instructions given. Home care to be done. Weight bearing restrictions. Labs, x-rays or other studies to be done. Follow up appointments. As with the assessment, this is often a list.
Inpatient Stuff Admission orders As a student orders and notes may be written, but need to be co-signed before they may be effected. In a sense, nothing happens without the nurses taking care of their business. Learn how their work flows and your job will be easier. Once the orders are written either a medical transcriptionist or a nurse will transcribe them. Each individual order will be noted in a specific place. Some (diagnosis, condition, etc) will simply be noted in certain areas of the patient's nursing records. Some orders will be noted in separate areas for recurring daily instructions (vital signs, activity level, nursing instructions such as dressing changes, etc.) These may be relegated to and followed through on by nursing assistants. Some instructions will need to be passed along to other services (such as dietary instructions, or PT). Medication orders will be noted separately. Different hospitals have different ways of taking care of these, so it might be worth looking at how they are done at any specific institution. A copy of the order will need to be forwarded to the pharmacy, so the medication will be available on the ward. Many common medications are kept in a ward stock, so they are readily available. Narcotics definitely fall in this category. Some places may use a "team" approach to nursing care. Here one nurse may be responsible for "treatments" and another responsible for medications. Find out how the nursing care works, and you may be better able to influence the care of your patient. If you are not sure how to do something, ask the nurses. They are there all the time, and know how to get things done. You need to know what needs to be done and convey that to them in the most effective manner. As long as all the information is there the format is not that critical. The ADCVANDILMAX format is frequently used, but is not the only mnemonic that can be used. ADCVANDISML is a little shorter, and works just as well. Use either or both when writing orders to help you think about all of the information that needs to be conveyed.
ADCVANDILMAX or ADCVANDISML
Admit to: Ward, unit or service; may note co-admit with attending internist. Diagnosis: May be a R/O type. Condition: Good, Stable, Guarded, Fair, Poor, Critical, Emergent. May have to include resuscitation status, per hospital protocol. Vital signs: How often, Q8H, Q4H. May include criteria for notification of House Officer. Activity: Ad lib, Bedrest, Bathroom privileges, OOB with assistance, Wheelchair, NWB, etc. Nursing: Special instructions for nursing staff. Dressing changes, Incentive spirometry, drain management, pre-op preps, etc. Diet: Regular, Diabetic (ADA, with cal restrictions), Low Na, NPO, etc. Ins & Outs: This may be how often you want I&O's checked, or may include what you want (IV's, Foleys, drains, etc.) Labs: Meds: May write for routine meds per internist. Include IV abx, PRN meds for pain, nausea/vomiting, sedatives, etc. Ancillary: Other stuff not covered elsewhere. Additional studies, PT, Social services consults, specific dressing supplies at bedside, etc. X-ray:
ADCVANDISML Admit to: Diagnosis: Condition: Vital signs: Activity: Nursing care: Diet: Ins & Outs: Special instructions: Include labs, x-rays, and ancillary stuff here. Medications: (Don’t forget to include allergies) Lines: IV’s, Foley's Drains, etc.
Progress Notes SOAP format, brief. Written on admission and on a regular basis after that. Usually twice a day, after morning and evening rounds. If needed, they can be written more frequently. In an ICU there will likely be several progress notes written each shift. They will also need to be written for various other reasons, like patient going to surgery. In some of these cases there are additional note formats that might be useful.
Orders After admission further orders can be written as needed. Newer orders will take precedence and cancel previous orders. For example, if you originally wrote for vital signs Q8H, and the patients condition changes, you may decide to write for vital signs Q4H. The previous orders will be changed. You may write new orders (e.g. add an Antibiotic). You may cancel (discontinue) orders as well. If you are unsure of how to write it or word it, ask the nurses how they want it done. If you let them know what you want to do, they can tell you how to best write it. As always, when in doubt, write it out.
Pre-Op Note May follow a SOAP format or a format similar to SAPPPPA HEMIC with some alterations. S: Pt is pre-op for procedure X. Note significant history, Allergies and Meds. Confirm NPO status per patient. O: H&P completed, no contraindications. Consent signed and on chart. Note EKGs, X-rays, and labs as appropriate. A:Pre-Op for procedure X P: Procedure X by Dr. Soanso. Type of anesthesia. Etc.
Modified SAPPPPA HEMIC Note Date and time Surgeon: Pre-Op diagnosis: Planned procedure: Consent: Should be signed and on the chart. Anesthesia: Type planned. Patient condition: NPO since (time), H&P completed with no contraindications to surgery. PMH: significant info. Allergies, Meds, Illnesses or condition. Labs: use shorthand notation. (MAY WANT TO USE DIAGRAMS) See above for diagrams used for Chem 10 and CBC. EKG/CXR if done. Note: Summary. Patient is here for X. No contraindications. No guarantees given or implied.
Post-Op SAPPPPA HEMIC Note Date and time, as well as start and end times for the operation. Surgeon: Assistants: Pre-Op Diagnosis: Post-Op Diagnosis: Procedure: Pathology: Anesthesia: Hemostasis: Tourniquet location, Type and Time EBL: (Estimated Blood Loss) Materials: Implants, dressings, etc. Injectibles: Stuff given Complications: Note: How the patient tolerated anesthesia and procedure. Their condition and vital signs when they left OR or went to RR. Include vascular and/or neuro status as applicable.
Discharge Discharge: Specify when, or if other clearance is needed. Instructions: Activities, Meds, Special care (dressing changes, etc.), problems to be aware of and instructions to seek additional care. Follow up appointment. May need to write separately for prescriptions and other medical devices. Should have written instructions for follow up care.
Physical Exam Vitals: General: Age, race, gender. Appearance and health HEENT: PERRLA. Pertinent findings. Neck: Lymph nodes? Carotid pulses? Bruits? JVD? Lungs: Distress? Chest rise? Accessory muscle use? Increased AP diameter? Auscultation? CV: Extremities – pulses? Edema? Cap refill? Temp? Auscultate rate, S1S2? S3S4? Bruits? Murmurs? GI/Abd: Countour, lesions, BS? Palpate? Liver/spleen/superficial/deep GU: LMP Musculoskeletal: Strength, ROM, joints, injuries. Neuro: Deficits? Muscle atrophy? Reflexes? LE PE Lower Limb PE: VDON Vascular Pulses DP/PT (1-2/4 normal) SPVPFT Edema (Pitting?) 0-3+ Hair growth Skin Temp (cool to warm distal to proximal) Derm Skin (turgor, texture, temp) Any lesions – (open, maceration, ulcers) describe Nails Calluses (location, type - HD, HM, IPK) Ortho Strength (0-none, 5- normal) ROM Deformity (bunion, hammertoes) Biomechanics Neuro Protective Threshold (Semmes Weinstein) Intact/not, where it stops DTR (0 absent, 2+ normal, 4+ hyperactive) Patellar (L2-4) Achilles (L5-S2) Vibratory sensation Proprioception Other Labs X-rays
The SOAP Format Lots of different types of notes can be made to fit the SOAP format. You’ll want to be very familiar with this one. It can be used for Outpatient notes in the clinic. It works just as well for progress notes on inpatients. It can be used for Pre-Op notes, but there may be better formats to help remember all the additional information needed for those. Subjective: This is where you put the patients story. Often the chief complaint is written in quotations using the patients own words. This may be very brief. Or it can be expanded to include the history of the present illness. NLDOCAT can be used here. Or it may be expanded to include The entire history. All of this material is subjective since it is what the patient is telling you. Depending on CC, consider everything, and document the essential points. Pick your questions well. If you don’t ask, they might not tell. Objective: This is where the data goes. Your physical exam goes here, as well as any labs, x-ray reposts or other ancillary studies. Many items this may be a simple lower extremity physical exam, which usually fits pretty well in a VDON format (Vascular, Derm, Ortho, Neuro). Again, this is only one way to organize the information. Any way is OK, as long as all the needed stuff gets there. Assessment This part is usually fairly short. This is your Diagnosis. It may be written out as a numbered list. You may also include some other important bits. You might include that they are diabetic, or neuropathic, if the current problem is an ulcer that is related to those conditions. If you do not have a definitive diagnosis, the assessment might be R/O osteomyelitis. Plan: Include here anything that was done or will be done. Treatments given in the office. Prescriptions given. Instructions given. Home care to be done. Weight bearing restrictions. Labs, x-rays or other studies to be done. Follow up appointments. As with the assessment, this is often a list.
Inpatient Stuff Admission orders As a student orders and notes may be written, but need to be co-signed before they may be effected. In a sense, nothing happens without the nurses taking care of their business. Learn how their work flows and your job will be easier. Once the orders are written either a medical transcriptionist or a nurse will transcribe them. Each individual order will be noted in a specific place. Some (diagnosis, condition, etc) will simply be noted in certain areas of the patient's nursing records. Some orders will be noted in separate areas for recurring daily instructions (vital signs, activity level, nursing instructions such as dressing changes, etc.) These may be relegated to and followed through on by nursing assistants. Some instructions will need to be passed along to other services (such as dietary instructions, or PT). Medication orders will be noted separately. Different hospitals have different ways of taking care of these, so it might be worth looking at how they are done at any specific institution. A copy of the order will need to be forwarded to the pharmacy, so the medication will be available on the ward. Many common medications are kept in a ward stock, so they are readily available. Narcotics definitely fall in this category. Some places may use a "team" approach to nursing care. Here one nurse may be responsible for "treatments" and another responsible for medications. Find out how the nursing care works, and you may be better able to influence the care of your patient. If you are not sure how to do something, ask the nurses. They are there all the time, and know how to get things done. You need to know what needs to be done and convey that to them in the most effective manner. As long as all the information is there the format is not that critical. The ADCVANDILMAX format is frequently used, but is not the only mnemonic that can be used. ADCVANDISML is a little shorter, and works just as well. Use either or both when writing orders to help you think about all of the information that needs to be conveyed.
ADCVANDILMAX or ADCVANDISML Admit to: Ward, unit or service; may note co-admit with attending internist. Diagnosis: May be a R/O type. Condition: Good, Stable, Guarded, Fair, Poor, Critical, Emergent. May have to include resuscitation status, per hospital protocol. Vital signs: How often, Q8H, Q4H. May include criteria for notification of House Officer. Activity: Ad lib, Bedrest, Bathroom privileges, OOB with assistance, Wheelchair, NWB, etc. Nursing: Special instructions for nursing staff. Dressing changes, Incentive spirometry, drain management, pre-op preps, etc. Diet: Regular, Diabetic (ADA, with cal restrictions), Low Na, NPO, etc. Ins & Outs: This may be how often you want I&O's checked, or may include what you want (IV's, Foleys, drains, etc.) Labs: Meds: May write for routine meds per internist. Include IV abx, PRN meds for pain, nausea/vomiting, sedatives, etc. Ancillary: Other stuff not covered elsewhere. Additional studies, PT, Social services consults, specific dressing supplies at bedside, etc. X-ray: ADCVANDISML Admit to: Diagnosis: Condition: Vital signs: Activity: Nursing care: Diet: Ins & Outs: Special instructions: Include labs, x-rays, and ancillary stuff here. Medications: (Don’t forget to include allergies) Lines: IV’s, Foley's Drains, etc.
Progress Notes SOAP format, brief. Written on admission and on a regular basis after that. Usually twice a day, after morning and evening rounds. If needed, they can be written more frequently. In an ICU there will likely be several progress notes written each shift. They will also need to be written for various other reasons, like patient going to surgery. In some of these cases there are additional note formats that might be useful.
Orders After admission further orders can be written as needed. Newer orders will take precedence and cancel previous orders. For example, if you originally wrote for vital signs Q8H, and the patients condition changes, you may decide to write for vital signs Q4H. The previous orders will be changed. You may write new orders (e.g. add an Antibiotic). You may cancel (discontinue) orders as well. If you are unsure of how to write it or word it, ask the nurses how they want it done. If you let them know what you want to do, they can tell you how to best write it. As always, when in doubt, write it out.
Pre-Op Note May follow a SOAP format or a format similar to SAPPPPA HEMIC with some alterations. S: Pt is pre-op for procedure X. Note significant history, Allergies and Meds. Confirm NPO status per patient. O: H&P completed, no contraindications. Consent signed and on chart. Note EKGs, X-rays, and labs as appropriate. A:Pre-Op for procedure X P: Procedure X by Dr. Soanso. Type of anesthesia. Etc.
Modified SAPPPPA HEMIC Note Date and time Surgeon: Pre-Op diagnosis: Planned procedure: Consent: Should be signed and on the chart. Anesthesia: Type planned. Patient condition: NPO since (time), H&P completed with no contraindications to surgery. PMH: significant info. Allergies, Meds, Illnesses or condition. Labs: use shorthand notation. (MAY WANT TO USE DIAGRAMS) See above for diagrams used for Chem 10 and CBC. EKG/CXR if done. Note: Summary. Patient is here for X. No contraindications. No guarantees given or implied.
Post-Op SAPPPPA HEMIC Note Date and time, as well as start and end times for the operation. Surgeon: Assistants: Pre-Op Diagnosis: Post-Op Diagnosis: Procedure: Pathology: Anesthesia: Hemostasis: Tourniquet location, Type and Time EBL: (Estimated Blood Loss) Materials: Implants, dressings, etc. Injectibles: Stuff given Complications: Note: How the patient tolerated anesthesia and procedure. Their condition and vital signs when they left OR or went to RR. Include vascular and/or neuro status as applicable.
Discharge Discharge: Specify when, or if other clearance is needed. Instructions: Activities, Meds, Special care (dressing changes, etc.), problems to be aware of and instructions to seek additional care. Follow up appointment. May need to write separately for prescriptions and other medical devices. Should have written instructions for follow up care.
Physical Exam
Vitals: General: Age, race, gender. Appearance and health HEENT: PERRLA. Pertinent findings. Neck: Lymph nodes? Carotid pulses? Bruits? JVD? Lungs: Distress? Chest rise? Accessory muscle use? Increased AP diameter? Auscultation? CV: Extremities – pulses? Edema? Cap refill? Temp? Auscultate rate, S1S2? S3S4? Bruits? Murmurs? GI/Abd: Countour, lesions, BS? Palpate? Liver/spleen/superficial/deep GU: LMP Musculoskeletal: Strength, ROM, joints, injuries. Neuro: Deficits? Muscle atrophy? Reflexes?
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