Medical Note Guidelines for ed rotations



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Medical Note Guidelines for ED Rotations
The following is one way to write your SOAP notes. I have described only normal examinations. You do not have to perform all these examinations on every patient, simply do focused exams on parts or systems involved in the patient’s chief complaint. However, I recommend always doing a brief heart and lung exam on all patients as a screening tool. Also, kids less than 3 years old get complete head to toe exams, including visualization of genitalia and palpation of testis, in almost every situation.


  1. Chief Complaint: cc: In patient’s own words.




  1. HPI (History of Present illness): Subjective - What the patient tells you. Include at least - How long, what makes it better or worse, any mechanism of injury, any relative/related circumstances/problems. You are not the patient’s secretary. Do not feel obligated to take dictation from the patient. Summarize what the patient tells you to compliment the image you have of the patient’s problem.

    1. Describe any pain using OPQRST (onset, palliative or provocative factors, quality (sharp, dull, aching, crampy), radiating, severity (1-10 scale or mild, moderate, severe), and timing (duration, intermittent or constant, waxing/waning)

    2. Level 5 Billing: Five or more of following categories providing a chronological description of illness: Location, Context: Description of where the patient was, or what they were doing when symptoms began, Quality, Timing: Description of when symptoms experienced, Severity: Quantify the symptoms (i.e. 1-10 scale) or descriptive (mild, moderate, severe, improving), Duration: How long has the patient been experiencing symptoms, Modifying Factors: What makes symptoms better or worse, Associated Signs and Symptoms: Other signs or symptoms the patient is or is not experiencing.

    3. If unable to obtain a history from the patient, family or others you MUST provide a reason that you are unable to obtain the history. (IE Patient intubated) This evokes the ED/acuity caveat and you still get credit for asking the questions.




  1. ROS: Review the systems potentially related to the patient’s complaint.

    1. Include some or all of the following: Allergic/Immunologic (i.e. itchy eyes, hives, rashes), Cardiovascular (i.e. pain, palpitations, and murmurs), Constitutional (i.e. fever, weight loss, strength), Ears, Nose, Mouth, Throat (i.e. nose bleeding, colds, obstruction, discharge, dental pain, neck stiffness), Endocrine (i.e. polyuria, polydipsia, intolerance to heat / cold), Eye (i.e. vision, double vision, tearing, blind spots, pain), Gastrointestinal (i.e. appetite, dysphagia, abdominal pain, heartburn, nausea, vomiting, diarrhea, jaundice if +N/V/D ask if vomiting and diarrhea is bilious (in vomiting = dark green/black color), bloody, or black (coffee ground emesis or melana), relationship to ingestion, projectile. Ask if diarrhea has blood or mucus), Genitourinary (i.e. urgency, frequency, dysuria, hematuria, (Female) – menses, regularity, last period) Hematologic / Lymphatic (i.e. bleeding tendency, lymph node enlargement), Integumentary - skin and/or breast - (i.e. rash, itching, pigmentation, dryness, swelling), Musculoskeletal (i.e. pain, swelling, redness, joints, weakness, cramps), Neurologic (i.e. convulsions, paralysis, tremor, loss of coordination, ataxia), Psychiatric (i.e. mood, anxiety, depression, hallucinations), Respiratory (i.e. pain, Shortness of breath, wheezing, stridor, cough, hemoptysis)

    2. Level 5 Billing: At least 10/14 body systems reviewed, pertinent positives and negatives. Write down at least pertinent positives/negatives then “all others negative.




  1. History:

    1. PMH (Medical Hx)

    2. PSHx (surgical Hx)

    3. FHx (Family Hx)

    4. SHx (Social Hx. Includes ETOH, Tobacco, work environment, and sexual habits if possibly applicable to chief complaint)

    5. OB/Menstrual Hx- LMP, GPtpal (Gravidity, Parity- term pregnancies (>37wks), premature deliveries (<37 wks and <2500gm), abortions (spontaneous or elective), living children)

    6. Risk factor analysis: if applicable review risk factors for PE or CAD

    7. PE Risk Factors: Immobility (Recent Major Surgery, long trip > 5 hours), Venous Damage (trauma), hypercoagulability (Hx of PE/DVT, Cancer, Nephrotic Syndrome, Collagen Vascular or other inflammatory Disease (RA, Lupus, etc), Recent Pregnancy (< 3 months post partum or currently pregnant))

    8. CAD Risk Factors: HTN, smoker, Hypercholesterolemia, + Fam Hx CAD/MI (immediate family only), known or previous CAD/MI, DM.

    9. Note any allergies (add what reaction occurred) or NKDA.

    10. Note any current meds being taken (OTC, or Rx, supplements, herbal remedies)

    11. Note immunization status. Especially important in children and wounds that may be tetanus prone.

    12. Level 5 Billing: Must provide at least two out of three categories: Past Medical History, Past Surgical History, Medications, Allergies, Family History, Social History.




  1. PE: Objective- What you can actually see, measure or discern. Do a focused PE based on the patient’s complaint. Always exam the heart, lungs, and abdomen except for minor extremity trauma in an otherwise healthy young person. The findings listed below indicate abbreviated exams with normal findings. A more detailed exam is required in many cases. Ensure to evaluate vitals signs.

    1. Constitutional- (i.e. vital signs, general appearance) Statement of General Health/Appearance: ND, A&Ox3 (or appropriate to age for small children). Add WDWN (well developed well nourished when describing small children and infants) If a temp is suspected be sure to request a rectal temp. Give interpretation of pulse ox. (example: if pulse ox is >= to 95% write “adequate”)

    2. HENT:

      1. Head- NCAT

      2. Ears- TMs pearl B, w/good landmarks

      3. Nose-no d/c/flaring

      4. Throat-clear

      5. Neck- supple, A/PFROM w/o pain or TTP, no midline TTP (in trauma)

    3. Eyes- PERRLA, EOMI, no d/c, moist. For slit lamp exams write: SLE: EOMI; PERRLA; LLL (Lids, Limbus, Lashes) quite; C/S (conjunctive/sclera) clear, no FB (foreign body) or injury; K (Cornea) clear, no abrasions; A/C (anterior chamber) quiet, no c/f (cell/flare); I (Iris) flat, round; Lens clear

    4. Respiratory- BBS (Bilateral Breath Sounds) w/good air exchange (in kids add: no retractions or accessory muscle use)

    5. Cardiovascular- (HS-Heart Sounds): S1, S2, No m/r/g, R3 (i.e. Regular Rate & Rhythm)

    6. Gastrointestinal- soft, BS present, no TTP, no CVA TTP Rectal- DRE (digital rectal exam) Nml, heme neg

    7. Gentourinary-

      1. Male: Ext gen nml male, no testicular/scrotal/epididymal masses or TTP, no inguinal bulging

      2. Pelvic: Ext gen nml female, scant white mucoid vag d/c, no cervical d/c, no CMT, OS closed, no adenexal masses or TTP, uterus smooth, firm, nontender, nulligravid

      3. OB: Note FHT and/or TVUS/TAUS results

    8. Musculoskeletal- UE and LE - FAROM w/o pain/TTP/erythema/deformity. Back – same as neck except don’t say “supple”

    9. Skin- no lesions, warm, dry (good turgor, cap refill <2sec if dehydration considered)

    10. Neurologic-

      1. CN 2-12 intact, C:D 0.3 OU, No papilledema

      2. Str 5/5 & Sym: B/T/D/WE/WF/G/Q/H/DF/PF/EHL/B (Biceps)/T (Triceps)/D (Deltoid)/WE (Wrist Extension)/WF (Wrist Flexion)/G (Grip)/ Q (Quadriceps)/H (Hamstrings)/DF (Dorsi Flexion)/PF (Plantar Flexion)/EHL (Extensor Hallicus Longus)

      3. Right and left side (list seperately if not symmetric)

      4. For concentrated hand exam include: G/I/O (Grip)/ (Interoseous)/ (Opposition)/ WE/ WF/ 2 pt discrimination intact @ Xmm (Up to 1 cm is normal but <5-6mm at either side of distal phalanx is expected)

      5. Sensation intact to touch and = B

      6. DTR's +2 = B (list reflexes tested, use a stick figure), toes down B

      7. Cerebellar/Romberg: neg Romberg neg pronator drift, /RAM/FNF/HTH/HTW (Rapid alternating movements, finger nose finger, heel toe heel, heel toe walk)

    11. Psychiatric- #1 below, is optional. However, #2 & #3 below, should be on all charts of discharged patients for risk stratification and justification of discharge.

      1. General evaluation use AMSIT: Appearance, Mood, Sensorium (A&O x3), Intellect (Mini Mental Status Exam: count back from 100 by 7’s, et.al.), Thought (clear, logical, goal directed, insight, voices, messages, ask, “If you found a letter on the sidewalk, what would you do with it?”)

      2. For Depression use SIG E CAPS: Sleep, Interests, Guilt, Decreased Energy level, Decreased Concentration, Increased or decreased appetite, increased or decreased psychomotor, suicidal thoughts. Major Depression is >5 of these for > 2 months.

      3. For suicide risk stratification and to manage your risk regarding patient disposition, use the modified SAD PERSONS scale: Sex (female more attempts, male more completions) male = 1, Age <19 or >45 = 1, Depression or hopelessness = 2 (use SIG E CAPS to assess), Prior attempts or psychiatric care = 1, Excessive ETOH or drug use = 1, Rational thought loss or change = 2, Separated/Divorced/Widowed = 1, Organized suicide plan or serious attempt = 2, No social supports = 1, Stated future intent = 2. Total give a rough idea of suicide risk: Low 1-4, Moderate 5-6, High >6. Low to moderate risk can probably be managed as an outpatient, high risk requires immediate mental health consultation.

    12. Hematologic/Lymphatic/Immunologic- bleeding tendency, lymph node enlargement

    13. Level 5 Billing: Examine at least 8/12 body systems documented. “Normal” exam is acceptable, “Abnormal” is not. Generally two positive or negative findings per organ system required unless “negative” or “normal”




  1. EDC: Emergency Department Course.

    1. Describe the patient’s reaction to any therapy provided in the department. Document serial exams and discharge exams.

    2. Address the patient’s pain when applicable. Indicate their response to your treatment, and what you plan to do for d/c tx. Say something like, “Min pain at d/c. Tylenol for d/c pain mgt.”

    3. Ensure to document results of all labs, radiology studies, EKG etc…




  1. Procedure Note: Include at least the following for non-emergent procedures, and as much of the following as practical for emergent procedures.

    1. Treatment options discussed.

    2. Informed written (or verbal) consent obtained.

      1. You do not need written consent to perform procedures that the patient came to the ED specifically to have done, like a laceration repair. Implied consent is evident in these cases.

      2. Obtain written consent for procedures like lumbar puncture, abscess I&D, sedations, and anything that implied consent is not obvious.

    3. Sterile prep…then describe the procedure briefly.

    4. Well tolerated. (hopefully)

    5. No complications. (hopefully)

    6. PT ED. (Patient education. Talk to your patient about post procedure care and concerns while you are doing the procedure to save time.)




  1. MDM: (Medical Decision Making) This paragraph should list your differential diagnosis and very briefly describe your thought process. This is a justification for your diagnosis and patient disposition. Particularly address why you do not think the patient may have some life threatening or high morbidity condition to justify discharging a high-risk patient. This would include complaints or presentations like chest pain, abdominal pain, fever in children, shortness of breath, or headache. To do this, simply list your Diff Dx and preface it like this, “Doubt MI, CHF, PE, TAR, Pneumonia.”




  1. Marshfield Score Sheet Criteria:

    1. Two out of three elements must be documented extensively:

    2. Number of Diagnoses / Management options point system

      1. Self limited or minor 1 point

      2. Established problem – stable or improves 1 point

      3. Established problem – worsening 2 points

      4. New problem – no additional workup 3 points

      5. New problem – additional workup 4 points

      6. Since almost all patients in the ED are new to us, nearly all problems they present with are “New”

    3. Amount / Complexity of Data Reviewed

      1. Review and/or order of labs 1 point

      2. Review and/or order of radiology tests 1 point

      3. Review and/or order of other tests (i.e. EKG) 1 point

      4. Discussion of tests with performing physician 1 point

      5. Review and summarization of old records 2 points

      6. Obtaining history from someone other than patient 2 points

      7. Discussion of case with another physician 2 points

      8. Independent visualization of image, EKG, specimen 2 points

    4. Risk (See reverse side of card for further description)

      1. Minimal 1 point

      2. Low 2 points

      3. Moderate 3 points

      4. High 4 points




Diagnosis/management options

0-1

2

3

4

Amount of data

0-1

2

3

4

Overall risk

Minimal

Low

Moderate

High

Level of MDM

Straightforward

99281



Low

99282



Moderate

99283


99284


High

99285






  1. A: Assessment- Indicate your diagnosis. CANNOT write any of the following for the diagnosis: R/O, Rule/out, MVA, possible, probable, versus or etiology unknown. If in doubt as to the diagnosis – write the symptom i.e. chest pain, palpitations, foot pain, etc as the diagnosis.




  1. P: Plan. Management, Plan, Disposition. In the ED there are places on the forms for this information. List what you do (labs, procedures, tests), what treatment is ordered (medications, therapy), any follow-up arranged and what discharge instructions you give the patient. Don’t duplicate information found elsewhere on the chart.




  1. Discharge Instructions: These are your instructions to the patient and usually include patient education, medication, and follow up instructions. Do not abbreviate and do not give follow up instructions that would be impossible to comply with. That will not pass the test in a court of law. In general say something like this, “Return to ER if: then list a few things that would indicate possible serious/significant/emergent deterioration in their condition.” End any instructions with this statement, “or any other emergent medical condition or concern.”




  1. Critical Care: Evaluation and Management of the unstable critically ill or injured patient requiring the devoted attention of the physician

    1. Physician DOES NOT need to be at the bedside, but must perform work directly related to the individual patient’s care

    2. Time DOES NOT need to be continuous; it can be totaled from several encounters on the same day

    3. Total time MUST exceed 30 minutes, and be documented on the medical record

    4. DOES NOT include time spent by residents managing the patient

    5. DOES NOT include time spent performing separately billable procedures

    6. DOES include conversations with family, EMS, physicians, results review, performing documentation and time at bedside




  1. Requirements for billing levels:







99281 (Level 1)

99282 (Level 2)

99283 (Level 3)

99284 (Level 4)

99285 (Level 5)

Chief Complaint

Necessary

Necessary

Necessary

Necessary

Necessary

HPI

Brief (1-3 elements)

Brief (1-3 elements)

Brief (1-3 elements)

Extended (4 or greater)

Extended (5 or greater)

ROS

No ROS needed

Problem Pertinent to CC

Problem Pertinent to CC

2-9 body systems

10 or greater body systems

PFSH

None Needed

None Needed

None Needed

1/3 needed

At least 2/3 needed

Physical Exam

1 area or system

2-4 areas or systems

2-4 areas or systems

5-7 areas or systems

8 or more systems (not areas)

MDM

Straightforward

Low Complexity

Moderate Complexity

Moderate Complexity

High Complexity

Problem Type

Self Limited or minor

Low to moderate severity

Moderate severity

High severity but not threat to life

High severity / Life threatening


Updated 7 Nov 2006


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