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Debra o 5 . · ull1van

GUIDE TO

THIRD EDITION

GUIDE TO

Clinical Documentation T H I R D E D I T I O N

Debra D. Sullivan, PhD, RN, PA-C Lead Advanced Practice Provider Academic Urology and Urogynecology of Arizona Litchfield Park, AZ Owner, Sullivan Consulting Services Medicolegal Consulting Glendale, AZ

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F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com

Copyright © 2019 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher.

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Library of Congress Cataloging-in-Publication Data

Names: Sullivan, Debra D., author. Title: Guide to clinical documentation/Debra D. Sullivan. Description: Third edition. | Philadelphia: F.A. Davis Company, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018019472 (print) | LCCN 2018019898 (ebook) | ISBN 9780803669994 | ISBN 9780803666627 (pbk.) Subjects: | MESH: Forms and Records Control--methods | Medical Records--standards Classification: LCC R697.P45 (ebook) | LCC R697.P45 (print) | NLM W 80 | DDC 651.5/04261--dc23 LC record available at https://lccn.loc.gov/2018019472

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Dedication

When I think back to 2004, when the first edition of this book was published, I think of a wonderful group of friends who were there to celebrate with me. As I anticipate the publication of the third edition, almost all of those same wonderful friends are still here, encouraging and supporting me, and cheering me on to the finish line. Sadly, my dear friend Candy left us much too soon, and I miss her sweet presence more than words can say. The essence of her heart and soul is with me always. For the remaining STUB-C friends (Kent, Donna, Paige, Jeff, John, Brianna, Justin, Tim, Carla, and Jeff ), thanks for your friendship, your love, and your constancy in my life through the past two decades. I couldn’t ask for a better group of people to share life with! I hope there are many more decades to come!

Not only have I been blessed with these incredible friends, but I am fortunate to have the most loving, caring, and supportive husband any woman could hope for. Greg is an unwavering source of encouragement and inspires and challenges me to be the best I can be. He has stood beside me without complaint through the days of writer’s block, looming deadlines, malfunctioning computers, and the often-self-imposed frenzy of my world. He has the insight to know when to cheer me on, when to make me take a break, and when to give me space. I am so grateful for his calming influence, his ability to make me laugh and not take myself too seriously, and all he does to keep things running smoothly in the Sullivan household. Thanks, Greg, for all this, and so much more. And I promise... no fourth edition!

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Reviewers

Gilbert Boissonneault, PhD, PA-C, DFAAPA Professor Division of Physician Assistant Studies Medical University of South Carolina Charleston, SC Elizabeth Brownlee, MPAS, PA-C Physician Assistant, Assistant Professor School of Physician Assistant Studies, College

of Medicine University of Florida Gainesville, FL Rhonda Glen Feldman, MHS, MSS, PA-C Program Director Physician Assistant University of New England Portland, ME Pat Kenney-Moore, EdD, PA-C Associate Director/Academic Coordinator/Associate

Professor School of Medicine, Division of Physician Assistant Education Oregon Health & Science University Portland, OR

Sara Haddow Liebel, MSA, PA-C Education Director/Associate Professor Physician Assistant Department, College

of Allied Health Sciences Augusta University Augusta, GA Nicole Schmitz, DNP, APRN, PNP, CHSE Assistant Professor Nursing Minnesota State University – Mankato Mankato, MN Emily K. Sheff, CMSRN, FNP, BC Assistant Professor School of Nursing MGH Institute of Health Professions Boston, MA

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Acknowledgments

It is interesting to me how each edition of this book has its own uniqueness. I have worked at a different place during the writing of each edition, and I hope that has resulted in a deep layering of experience and knowledge that makes each edition better. I certainly feel like each job change has enhanced my professional practice and has enriched me as a person. I have met and worked with some extraordinary health-care providers, and I have had valuable contributions from so many of them.

First, I would like to say thank you to my colleagues at Academic Urology and Urogynecology of Arizona. I have had such encouragement and support from this great group of people. I am grateful to have learned from so many outstanding health-care providers throughout my more than 27 years in medicine. I have benefitted from the expertise of Jamie Bair, NP (cardiology); Jennifer Nelson, PA-C (psychiatry); Steve Turner, RN (hospice); Dr. Richard Guthrie (palliative care); and several outstanding hospitalists who wished to remain nameless. I’m thankful for a group of dedicated Information Technology people who have helped me navigate electronic medical records and who’ve answered my questions with enthusiasm.

I must take this opportunity to acknowledge two incredible women who added so much to the Document Library that we included in this edition of the book: Madison Palmer, MMS, PA-C, not only contributed the prenatal records, but she also provided valuable assistance with content in the prenatal chapter. Larissa J. Bech, MSN, RN, FNP-C contributed the pediatric records. Without their contributions, the prenatal and pediatric visit notes would not exist. They

bring real-world knowledge and hands-on patient care experience where I would only have been able to read and write about what others do.

There is a tremendous team of people at F. A. Davis who have been part of this project. Even though he retired before this edition was published, my dear friend Andy McPhee was the driving (cajoling? bullying?) force behind the third edition. I hope he is enjoying his much-deserved retirement and getting to write what he wants, when he wants, if he wants. When Andy approached me about a third edition, one of the most anxiety-producing aspects of considering it was who would be the developmental editor because I had less-than-wonderful experiences on the two previous editions. I need not have worried at all, as I have had the very good fortune to work with Stephanie Kelly, developmental editor extraordinaire! Stephanie’s knowledge of the process, her organizational skills, her sense of humor, and her hard work have made the journey so enjoyable, and she has my deepest gratitude. I’m also grateful for the guidance of and contributions from Melissa Duffield, Senior Acquisitions Editor; George Lang, Director of Content Development; Amelia Blevins, Developmental Editor for Digital Products; Megan Suermann, Content Project Manager; Lori Bradshaw, Developmental Production Editor at S4Carlisle Publishing; and Robert Butler, Production Manager. There’s probably not another publishing com- pany around that would have supported this project as F. A. Davis has done, and I’m humbled and honored they chose to champion this book. —Debbie Sullivan

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Brief Contents

Part 1: Foundations of Documentation

Chapter 1 Medicolegal Principles of Documentation 1

Chapter 2 The Comprehensive History and Physical Examination 23

Chapter 3 SOAP Notes 45

Part II: Documentation Related to Outpatient Care

Chapter 4 Documenting Prenatal Care and Perinatal Events 79

Chapter 5 Pediatric Preventive Care Visits 93

Chapter 6 Adult Preventive Care Visits 125

Chapter 7 Older Adult Preventive Care Visits 153

Chapter 8 Outpatient Charting and Communication 173

Chapter 9 Prescription Writing and Electronic Prescribing 195

Part III: Documentation Related to Inpatient Care

Chapter 10 Admitting a Patient to the Hospital 217

Chapter 11 Documenting Inpatient Care 257

Chapter 12 Discharging Patients from the Hospital 285

Appendices

Appendix A Document Library 309

Appendix B A Guide to Sexual History Taking 373

Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 375

Bibliography 377

Index 387

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Contents

Part 1: Foundations of Documentation

Chapter 1 Medicolegal Principles of Documentation 1

Learning Outcomes 1

Introduction 1

Medical Considerations of Documentation 2

Legal Considerations of Documentation 2

Other Types of Documents 272

Procedure Note 272

Summary 274

Worksheets 275

Chapter 12 Discharging Patients from the Hospital 285

Learning Outcomes 285

Introduction 285

Discharge Orders 285

Disposition 286

Activity Level 286

Diet 286

Medication Reconciliation 286

Follow-Up Care and Notification Instructions 287

Discharge Summary 288

Dates of Admission and Discharge 288

Admitting and Discharge Diagnosis (or Diagnoses) 288

Attending Physician, Primary Provider, and Consulting Physician 289

Procedures 289

Brief History, Pertinent Physical Examination Findings, and Pertinent Laboratory Values 289

Hospital Course 290

Condition at Discharge 291

Disposition, Discharge Medications, Discharge Instructions, and Follow-Up Instructions 291

Patient Leaving Before Discharge 291

AMA 291

Elopement 293

Summary 294

Worksheets 295

xviii | Contents

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Appendices

Appendix A Document Library 309

Appendix B A Guide to Sexual History Taking 373

Appendix C ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations 375

Bibliography 377

Index 387

Contents | xix

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Introduction

It’s no secret that medicine is constantly changing and evolving, but I guess I didn’t realize that there have been so many changes and evolutions in documentation until I started working on the third edition. Since the second edition was published in 2011, there have been signif- icant changes in coding, billing, reimbursable services, federal requirements for documentation, platforms for documentation, and so on. And, thanks to the feedback from users of this text and thoughtful reviews by edu- cators and practitioners, the “wish list” of content for this text has changed as well. So, here you have it, the third—and by far, the best—edition. One thing that has not changed is the basic principle of the book—this is an instructional work on documentation and is not meant to be an instructional work on the practice of medicine. Documentation and the practice of medicine are interrelated, and it is sometimes a challenge to keep them separate. However, they are two distinctly differ- ent practices. As an educator, I teach. As a Physician Assistant, I practice medicine. As an author, sometimes I want to do both, but that has never been the goal. The goal is to provide a solid foundation of principles of documentation that will preserve important aspects of the health-care provider–patient encounter while meeting the requirements for reimbursement and other regulations. There are many examples of documenta- tion of various encounters throughout this book, and each is just one example of how an encounter may be documented. There is not just one way to document any encounter but many different ways; and different doesn’t mean “good” and “bad”—just different. I’m of the opinion that the more examples you see, the more you will learn and the more prepared you will be when it comes time for you to document your way.

Revisions started with the Table of Contents, which has been expanded to highlight sections within the

chapters and to provide much more detail about the content. New content includes Chapter 4, Documenting Prenatal Care and Perinatal Events, and Chapter 7, Older Adult Preventive Care Visits. Some chapters were relocated within the text to present a more chronological sequence. Every chapter was revised; some revisions were fairly minor, whereas others were extensive. Medicolegal Alerts are included in each chapter to help highlight important concepts. New to this edition are images of electronic medical record (EMR) entries, or screen shots. There are multiple EMR systems available, so what is presented may look different from what you’ve seen before, but I think it is helpful to see sample entries from different systems.

Sometimes Appendices don’t get a lot of attention, but I hope you’ll check out Appendix A, the Document Library. In the library, you’ll find documents that per- tain to a particular patient grouped together in a way that captures the patient’s care chronologically. This provides a different perspective than seeing them as “stand-alone” documents in multiple chapters.

Many educators mentioned that they would like the worksheet answers moved out of the book so that they could be used more effectively as an educational tool, so this was done. You can find them in the Instructor’s Guide, at DavisPlus on the F.A. Davis website, which will allow you to provide them to the students as you see fit—you can simply provide the answers so students can check their own work, or you can use the worksheets as graded assignments.

Whether you are a student, a novice practitioner, or an experienced provider, I hope this book will be a valuable resource in your journey of professional development. —Debbie Sullivan Phoenix, Arizona

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Medicolegal Principles of Documentation LEARNING OUTCOMES

• Discuss medical and legal considerations of documentation. • Identify groups of people who may access medical records. • Identify general principles of documentation. • Discuss medical coding and billing. • Define the terms electronic medical records, meaningful use, and interoperability. • Identify benefits of using electronic medical records. • Identify challenges and barriers to using electronic medical records. • Identify components of the Health Insurance Portability and Accountability Act. • Discuss principles of confidentiality.

Introduction You might be asking, “Why a book on documentation?” Documentation is one of the most important skills a health-care provider can learn. You might feel tempted to focus considerably more time and energy on learning other skills, such as physical examination, suturing, or pharmacotherapeutics. These are essential skills, but documentation is likewise extremely important. State licensure laws and regulations, accrediting bodies, professional organizations, and federal reimbursement programs all require that health-care providers maintain a record for each of their patients.

Documentation used to be mostly a memory aid for the provider—a quick note of his or her thoughts about a patient’s presentation, a likely diagnosis, maybe a few words about the treatment plan. Over the past few decades, however, documentation has become a more complex task due to changes in medicine and with patients themselves. Increased complexity in the medical field is evident by the ever-increasing number of medications and treatment modalities available to health-care providers. In addition, patients live longer with a greater number of comorbid conditions, adding to the complexity of caring for them and requiring that complexity in the medical records. The fact that our so- ciety is so litigious certainly adds more weight to clinical

documentation and puts a greater burden on providers to capture their thoughts and actions for others to read and interpret years after an episode of care took place.

Dr. Mitchell Cohen wrote about this evolution of documentation in an article that appeared in Family Practice Management.* Dr. Cohen explains:

From time to time I’ll stumble upon an old chart in my office that goes back 40 years. My predecessors charted office visits on sheets of lined manila card stock, which would suffice for at least 15 to 20 visits. Clearly, these charts were only intended for the physicians as a way to refresh their memory of what happened from one visit to the next. For example, the documentation for one visit read simply, “1/20/67: pharyngitis >> penicillin.” These days chart notes are primarily not for the physician or patient, but for all the others who aren’t in the exam room and yet feel they have a stake in what takes place in this once confidential arena. To satisfy coders and insurers, my documentation for a 99213 sore throat visit must contain one to three elements of the history of present illness, a pertinent review of systems, six to 11 elements of the physical exam, and low-complexity medical decision-making. My malpractice carrier and my future defense attorney would also like me to explain my clinical rationale for why the patient has strep throat and not a retropharyngeal abscess or meningitis. A table with a McIsaac score calculating the likelihood that this

PART I Foundations of Documentation

Chapter 1

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2 | Guide to Clinical Documentation

patient does indeed have strep throat might be nice as well. If I prescribe a weak narcotic for a really nasty case of strep, the state medical board would be pleased if I addressed what other medications have been tried and whether the patient has any history of addiction. I’ll also need to document that I explained the proper use of the medications and the need for follow up if the patient doesn’t get better. When I’m finally done with my note, it looks like this:

CC: sore throat x 2d HPI: 17 y/o F with 2d h/o sore throat. Has an asso-

ciated headache and fever to 1018F. No significant cough. Patient has noticed some swollen lumps in neck. Having significant pain despite use of Tylenol, ibuprofen and salt water gargles.

Social Hx: no h/o substance abuse or addiction. ROS: denies neck stiffness or back pain, no rash. No

difficulty speaking. PE: VS: AF, VSS Gen: alert, pleasant female in NAD HEENT: NC/AT, PERRLA, EOMI, TM clear b/l,

OP notable for tonsillar enlargement with exudates. No asymmetry or uvular deviation present.

Neck: + tender anterior cervical adenopathy, no nuchal rigidity or meningismus.

CV: RRR S1/S2 without murmurs. C/L: CTAB Abd: soft, nondistended, nontender, no hepatosplenomegaly. McIsaac’s score = 4; Rapid strep + A: streptococcal pharyngitis P: 1) Pen VK 500 mg po TID x 10 days. Discussed

risks of medication including allergic reaction and complications of not taking full course of antibiotics including rheumatic fever and valvular heart disease.

2) hydrocodone elixir q HS to help relieve pain par- ticularly when trying to rest. Has already tried acetaminophen and NSAID and will continue salt water gargles. Follow up if no improvement in one week. Have discussed other potential diagnoses and reviewed warning signs of retropharyngeal abscess and meningitis. Patient agrees and understands plan.

Like I said, “pharyngitis >> penicillin.” (*Used with permission of the American Academy of Family Physicians)

Medical Considerations of Documentation As illustrated in the example, the medical record serves to document the details of the patient’s complaint and the medical evaluation and treatment. The medical

record also serves other purposes and has audiences other than the patient and the health-care provider; it is both a medical and a legal document. The medical record establishes your credibility as a health-care provider. It is important to remember that you are creating a record that other professionals will read; therefore, you should use professional language and include appropriate content. Other readers will assume, rightly or wrongly, that you practice medicine in much the same way that you document. If your documentation is sloppy, full of errors, or incomplete, others will assume that is the way you practice. Conversely, thorough, legible, and complete documentation will infer that you provide care in the same way, thus establishing your credibility. Some excellent providers simply do not have good doc- umentation skills. However, this is the exception rather than the rule. It is very difficult to persuade those who read sloppy documentation that the person who wrote that way can, and did, provide good care.

Up-to-date and complete documentation is an essential component of quality patient care. The medical record is the primary means of communication between mem- bers of the health-care team and facilitates continuity of care and communication among the professionals involved in a patient’s care. Although many patients will have a primary care provider who provides most of their care, patients also may see specialists for specific problems. Medical records are the vehicle for com- munication among members of the health-care team, and the medical record is the common storehouse for all information about the patient’s care and condition regardless of who is providing that care.

Legal Considerations of Documentation As mentioned previously, all medical records are legal documents and are important for both the health- care provider and the patient, regardless of where the patient care takes place. The most important legal functions of medical records are to provide evidence that appropriate care was given and to document the patient’s response to that care. An often-quoted principle of documentation, which every health-care provider has probably heard, is that if it is not doc- umented, it was not done. This is a fallacy because it is impossible to capture with documentation every nuance of a patient–provider encounter, and it is im- possible to create a perfect record of every encounter. However, the principle behind the quote is important in a legal context; there is a considerable time lapse between when events occur (and are documented) and when litigation occurs. It may be anywhere from

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Chapter 1 Medicolegal Principles of Documentation | 3

2 to 7 years from the occurrence of an event until you are called to give a sworn account of the event. The medical record is usually the only detailed record of what actually occurred, and only what is written is considered to have occurred. You will not remember the details of an event that happened 6 years ago; your only memory aid will be the medical record. As a legal document, the medical record that you authored will be made available to plaintiff attorneys, defense attorneys, malpractice carriers, jurors, judges, and, most likely, the patient. You should keep this in mind at all times when documenting.

The record should be objective. Personal, subjective opinions regarding the patient, the patient’s family, or other providers do not belong in the medical record. It is human nature to make value judgments about others, but it is asking for trouble to note in a record those irrelevant judgments about the patient. Document facts; not opinions. All providers should strive for accuracy in documentation. Correcting a medical record is not only encouraged, but it is necessary in order to avoid potentially harmful mistakes or misrepresentations. Altering a record should never be done. Alteration con- notes an improper change, concealment, or omission of portions of records that were written inappropriately. Correction implies the act of making something right. Record alterations have rendered many defensible cases indefensible. Most jurors will suspect that a provider who alters records has done so to cover up a mistake. The opposing attorney will argue that alteration shows consciousness of guilt. Alterations in medical records may give rise to a claim for punitive damages against a provider. Intentionally altering or destroying a patient’s chart is considered unprofessional conduct. Most states will consider a practitioner who alters or destroys a patient’s chart to have violated the applicable licensing statute and will sanction or suspend the practitioner’s license to practice medicine.

Other Purposes of Documentation Reviewers from various organizations can obtain access to a medical record for a variety of purposes. Health-care payers require reasonable documentation for a number of reasons: • To ensure that a service is consistent with the pa-

tient’s insurance coverage • To validate the site of service, medical necessity,

and appropriateness of the diagnostic and/or therapeutic services provided

• To confirm that services furnished were accurately reported

Clear and concise documentation is required to receive accurate and timely payment for furnished services. Peer-review organizations might read the record to determine whether the care reflected in your doc- umentation is consistent with the standard of care. Researchers often obtain access to medical records for purposes of conducting scientific studies. Although it is important to remember that these audiences may have access to your records, you should keep in mind that the primary audience of the medical records will be medical professionals involved in direct patient care.

Throughout this book, you will analyze examples of documentation. You may also complete the worksheets, which will help you apply the information as you read it. The purpose of this book is to teach documentation skills and critical analysis of medical records, not to instruct on the practice of medicine or to teach medical decision-making. The content of a medical record—or learning what to document—varies greatly, depending on the patient’s presenting problem or condition. The principles of how to document and why documentation is important do not vary as much and, thus, are the focus throughout this book.

General Principles of Documentation The Centers for Medicare and Medicaid Services (CMS) is one agency of the U.S. Department of Health and Human Services (HHS). As one of the nation’s largest payers for health-care services, CMS has established specific guidelines for documentation that are referenced several times throughout this book. There are two sets of documentation guidelines currently in use: the 1995 and the 1997 guidelines. CMS published an evaluation and management guide in 2015; however, it was offered as a reference tool and did not replace the content found in the 1995 and 1997 guidelines. There are minor differences between the two guidelines, and it is recommended that health-care providers refer to the guidelines to identify those differences. Additional information may be found at www.cms.gov/Outreach-and-Education/ Medicare-Learning-Network-MLN/MLNProducts/ Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

Both sets of guidelines recognize the following general principles of documentation: 1. The medical record should be complete and

legible. 2. The documentation of each patient encounter

should include the following: • Reason for the encounter and relevant history,

physical examination findings, and diagnostic test results

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4 | Guide to Clinical Documentation

systems create a “digital footprint” every time a record is accessed. This digital footprint includes the date and time and the identity (typically name and title and/or role) of the person accessing the record. The system also will indicate the time and date of any updates or changes made to the record. You should never document in a patient’s record in advance of seeing the patient. In addition, you can correct or amend a patient’s medical record, but you should never alter it. At times, it will be necessary to make corrections to a record. When making a correction in a paper record, you should draw a single line through the text that is erroneous, initial and date the entry, and label it as an error. If there is room, you may enter the correct text in the same area of the note. You should not write in the margins of a page; if there is no room to enter the correct text, use an addendum to record the information. You should never obliterate an original note, nor should you use correction fluid or tape. In the EMR, once a document is submitted, it is still possible to modify or correct the record. If an entire entry is incorrect (for exam- ple, charting on the wrong patient), there is a process to identify the entry as an erroneous document. The process will vary with different EMR systems, and institutions will have their own policy for identifying erroneous entries.

Based on your reading, complete the application exercise that follows.

• Assessment, clinical impression, or diagnosis • Plan for care • Date and legible identity of the health-care

provider 3. If not documented, the rationale for ordering

diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and consulting providers.

5. Appropriate health risk factors should be identified.

6. The patient’s progress, response to and changes in treatment, and revision of diagnoses should be documented.

7. The diagnosis and treatment codes reported on the health insurance claim form or billing state- ment should be supported by the documentation in the medical records. (More discussion of bill- ing and coding is included later in this chapter.)

There are other generally accepted principles of documentation, such as that each entry should include the date and time the record was created and should identify the person creating the record. In settings in which care is provided around the clock, military time is often used to avoid confusion between a.m. and p.m. One o’clock in the afternoon is 1300, 10:30 at night is 2230, and so forth. Electronic medical record (EMR)

Application Exercise 1.1 After seeing patient E. H. and documenting the encounter, you realize that you previously entered medications and allergies for another patient in E. H.’s chart. Correct the record to show the correct medications as follows: Zocor 20 mg daily, metformin 500 mg daily, Synthroid 0.125 mg daily. PMH: E. H. has a history of type 2 diabetes (diagnosed at age 41), hypothyroidism (diagnosed at age 37), and hyperlipidemia (diagnosed at age 39). Surgical history includes tonsillectomy as a child and cholecystectomy at age 42. Medications include Lasix 20 mg daily, Diovan 80 mg daily, warfarin 5 mg daily, and vitamin D, 2 capsules daily. Allergic to sulfa drugs. Family history is positive for diabetes in mother and maternal grandmother and heart disease in paternal grandfather.

Application Exercise 1.1 Answer

PMH: E. H. has a history of type 2 diabetes (diagnosed at age 41); hypothyroidism (diagnosed at age 37), and hyperlipidemia

(diagnosed at age 39). Surgical history includes tonsillectomy as a child and cholecystectomy at age 42. Medications include

Lasix 20 mg daily, Diovan 80 mg daily, Warfarin 5 mg daily, and vitamin D, 2 capsules daily. Allergic to sulfa drugs.

Family history is positive for diabetes in mother and maternal grandmother, and heart disease in paternal grandfather.

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If using a ruled sheet such as an order sheet or progress note, be sure that there are no blank lines. If a record is dictated and then transcribed, read the transcription before signing it, correcting any errors in the process. You should not stamp a record “signed but

not read” or “dictated but not reviewed” because doing so will call attention to the fact that you did not verify the content of the record.

When entering the medical field, you must learn the language in order to function. Part of learning this language

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Chapter 1 Medicolegal Principles of Documentation | 5

with a hyphen. The third category of CPT codes cor- responds to emerging medical technology. There are approximately 7,800 CPT codes, and the codes are updated annually.

Evaluation and Management Services When a patient presents for care, you as the health-care provider evaluate the patient and then proceed to manage the presenting complaint. That encounter between you and the patient may vary from brief to comprehen- sive depending on the patient’s chief complaint. For example, the time required for evaluation of a child who presents with a sore throat is typically brief, and the management options are fairly straightforward. Conversely, more time is required for evaluating an older adult who has several chronic conditions and a new complaint of chest pain, and the evaluation and management process is more complex.

CPT codes assigned for E/M services are deter- mined by several factors. One factor is whether the patient is new, established, or seen for consultation services, and another is the setting where care is provided. Complexity of service is another factor and is determined by three key elements: history (including history of present illness [HPI]; review of systems [ROS]; and past medical, family, and social history [PMFSH], which are explored in Chapter 2), physical examination, and medical decision-making. The complexity considers the presenting complaint, co-existing medical problems, amount of data to be reviewed (i.e., tests and old records), amount of time that you spend with the patient, number of diagnoses and treatment options, and risk for significant com- plications. Table 1-1 summarizes the requirements for each level of E/M based on history, physical exam- ination, and complexity of medical decision-making. In the case where counseling and/or coordination of care constitutes more than 50% of the encounter, time is considered the key or controlling factor to qualify for a particular level of E/M services. This includes time spent with parties who have assumed responsibility for the care of or decision-making for the patient. If you elect to report the level of service based on counseling and/or coordination of care, then you would document the total length of time of the encounter, and you should describe in the record the counseling and/or activities performed to coordinate care. Counseling includes discussion of diagnostic results, impressions, and/or recommended diagnostic studies; prognosis; risks and benefits of management options; instructions for management and/or follow-up; importance of compliance with chosen management (treatment) options; risk factor reduction; and patient and family education. An example of documentation of time spent with a patient is shown in Example 1.1.

is to learn the meaning of the abbreviations, acronyms, and symbols in use; therefore, they are incorporated in this text. Abbreviations are a convenience, a time saver, a space saver, and a way of avoiding the possibility of misspelled words. Incorporating abbreviations is not an endorsement of their legitimacy, but it is intended to assist individuals in reading and understanding medically related documents. Sometimes abbreviations are not understood. They can be misread or interpreted incorrectly. For example, the abbreviation “CP” could mean “chest pain” or “cerebral palsy.” Of course, the rest of the entry should make clear the term for which the abbreviation is being used. There are variations in how an abbreviation can be expressed. “Anterior-posterior” has been written as AP, A.P., A/P. Abbreviations may appear as all uppercase or all lowercase, and they may or may not have periods after each letter (for example, PRN, prn, P.R.N., meaning “as needed”). Many inherent problems associated with abbreviations contribute to or cause errors. Health-care organizations should for- mulate a “Do Not Use” list of dangerous abbreviations, and you as the health-care provider are responsible for complying with your institution’s policies regarding use of abbreviations.

Medical Coding and Billing Concise documentation of the medical encounter is critical to providing patients with quality care and to ensuring accurate and timely reimbursement. Medi- cal records are subject to review by payers to validate that the services provided were medically necessary and were consistent with the individual’s insurance coverage. Standard codes are assigned to reflect the health-care diagnosis, procedures, and medical ser- vices provided and to create a uniform vocabulary for claims processing, medical care review, medical education, and research. Two important code sets are the Current Procedure Terminology (CPT) and the International Classification of Diseases (ICD) codes. CPT codes are used to document many of the med- ical procedures performed in a physician’s office. This code set is published and maintained by the American Medical Association (AMA). CPT codes are five-digit numeric codes that are divided into three categories. The first category is used most often, and it is divided into six ranges that correspond to six major medical fields: Evaluation and Management (E/M; discussed in more detail next), Anesthesia, Surgery, Radiology, Pathology and Laboratory, and Medicine. The second category of CPT codes corresponds to performance measurement and, in some cases, laboratory or radiology test results. Typically, these five-digit, alphanumeric codes are added to the end of a Category I CPT code

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Level of History HPI ROS PMFSH Problem focused Brief (one to three elements) None None Expanded problem

focused Brief (one to three elements) One system None

Detailed Extended (four or more elements)

Two to nine systems One pertinent PMFSH (one from any of the three)

Comprehensive Extended (four or more elements)

10 or more systems Complete PMFSH

Type of Physical Examination Examination Description 1995 Guidelines 1997 Guidelines Problem focused Limited to affected body area or

organ system One body area or organ

system One to five bulleted items

Expanded problem focused

Affected body area/organ system and other symptomatic or related organ system(s)

Two to seven body areas or organ systems

Six to 11 bulleted items

Detailed Affected body area/organ system and other symptomatic or related organ system(s)

Two to seven body areas or organ systems

12 to 17 bulleted items for two or more systems

Comprehensive General multisystem Greater than eight body areas or organ systems

18 or more for nine or more systems

Medical Decision-Making

Number of Treatment Options

Amount of Data (Diagnostic Studies, Prior Records)

Risk for Complications, Morbidity and/or Mortality

Straightforward One or less One or less Minimal Low Two Two Low Moderate Three Three Moderate

High Four or more Four or more High

Table 1-1 Levels of Evaluation and Management Based on History, Physical Examination, and Complexity of Medical Decision-Making

EXAMPLE 1.1

J.K. is a 62-year-old established patient who comes in to discuss use of cholesterol lowering medication. More than half of the time of the encounter was spent providing patient education and counseling, and you document the following:

A total of 15 minutes was spent face-to-face with the patient during this encounter, and over half of that time was spent on counseling. We discussed in-depth the results of his most recent labs, specifically high cholesterol and tr iglyceride levels , his r isk factors for coronar y disease (smoking, high cholesterol, and family histor y), and the importance of primar y prevention of coronar y disease with aggressive treatment of high choles- terol. I also educated the patient about lifestyle modifications that may improve blood pressure and help lower cholesterol.

International Classification of Diseases Coding Whereas CPT codes indicate what services and procedures were provided, the ICD codes explain the reason for the services. The ICD code is a diagnostic coding system that classifies diseases and injuries and is used to track

mortality and morbidity statistics. These standardized codes are used by national and international agencies and organizations to forecast health-care needs, evaluate facilities and services, review costs, and conduct studies of trends in diseases over the years. ICD was established by the World Health Organization in the late 1940s and has been updated several times in the years since its inception. The number following “ICD” represents which revision of the code is in use; therefore, “ICD-10” represents the 10th revision. ICD-10 has more than 155,000 codes and has the capacity to accommodate new diagnoses and procedures, expand descriptions of some diagnoses, and allow more detailed tracking of mortality and morbidity. The ICD codes are updated every October; therefore, health-care providers and coding and billing personnel must ensure that they are using the most up-to-date code set.

An ICD code is assigned to identify the diagnosis, symptom, condition, problem, complaint, or other reason for the encounter. When assigning a diagnosis and code, you should be as descriptive as the data allow and use medical terminology rather than lay terminology. For example, instead of documenting “runny nose,” you should use “rhinorrhea.” This does not work in every situation;

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The primary code would be abdominal pain (R10.10 if upper abdominal pain or R10.30 if lower abdominal pain).

4. Secondary codes are listed after the primary code and expand on the primary code or define the need for a higher level of service. • In the previous example, if the patient with

abdominal pain has bloody vomitus, then hematemesis (K.92) would be coded as a secondary diagnosis.

5. Code a chronic condition as often as applicable to the patient’s condition. • Using example 3, the patient’s history of de-

pression may not be pertinent to the complaint of abdominal pain, so it would not be coded; however, diabetes would be coded.

6. Code co-existing conditions that may have an influence on the outcome. • In example 3, depression is a co-existing

condition that may alter a patient’s percep- tion of abdominal pain. The patient may take antidepressant medication, which could cause the pain. Coding both the chronic condition ( diabetes) and co-existing condition (depres- sion) demonstrates the higher level of care needed to manage the patient.

7. Do not use “rule out . . .” as a diagnosis. • There is no code for this. Instead, use a

diagnosis, symptom, condition, or problem. You may use “rule out” when documenting the assessment to guide you in your plan of care, although it is not necessary.

8. Signs and symptoms that are routinely associ- ated with a disease process should not be coded separately. • An upper respiratory infection (URI) is typ-

ically associated with pharyngitis, rhinitis, and cough. Pharyngitis, rhinitis, and cough each have a distinct ICD-10 code ( J02.9, J00, and R05, respectively), but the code for URI ( J06.9) is used because it encompasses these symptoms.

9. When the same condition is described as both acute and chronic, code both and use the acute code first. • A patient may have an acute exacerbation

( J01.90) of chronic sinusitis ( J32.9). Accurate billing and coding is necessary to capture as much revenue as possible. The information presented here is meant to be illustrative in nature and is by no means adequate treatment of the subject and should not be relied on as authoritative. Many excellent resources are readily available to assist those who desire more information on this topic.

there is no medical term for “chest pain” when used as a diagnosis, unless you know what is causing the chest pain. When claims are submitted for payment, both CPT and ICD codes are provided, and your documentation must support the level of service billed. CPT codes work in tandem with ICD codes to create a full picture of the medical process for the payer; “this patient arrived with these symptoms (as represented by ICD codes) and these procedures were performed” (represented by CPT codes). Downcoding is the process by which an insurance company reduces the value of a procedure or encounter and resulting reimbursement because either (1) there is a mismatch of CPT code and description, or (2) the ICD code does not justify the procedure or level of service. The quality and accuracy of the medical record are vital to the reimbursement process, which, in turn, is vital to the delivery of health care.

MEDICOLEGAL ALERT !

Although getting paid is a very important issue for health-care providers, you should never code for re- imbursement purposes only. This can be construed as fraud. Remember, your documentation must support the level of service and the diagnoses reported.

Good documentation is absolutely essential to support the level of E/M services and facilitate assignment of correct CPT and ICD codes. Here are some key con- cepts showing the interrelatedness of documentation and codes and an illustrative example of each concept: 1. Any tests ordered must correlate with an ICD

code assigned to the visit. • If a urine pregnancy test is performed, a rea-

son for obtaining that test must be associated with a diagnosis, such as secondary amenor- rhea (N91.1), menometrorrhagia (N92.0), or abdominal pain (R10.10 if upper abdominal pain or R10.30 if lower abdominal pain).

2. Assign an ICD code that reflects the most specific diagnosis that is known at the time. • A patient’s diagnosis is gastroenteritis (K52.9).

If it is reasonably certain that it is viral, use the code for viral gastroenteritis, A08.4. Suppose that the patient’s original complaint was di- arrhea (R19.7). The result of a stool culture is positive for shigella. When the patient returns for a follow-up visit, then the diagnosis would be enteritis, shigella (A03.9).

3. The primary code should reflect the patient’s chief complaint or the reason for the encounter. • A patient with a history of depression and

diabetes presents with acute abdominal pain.

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an electronic medical records system should be capable of performing: 1. Health information and data 2. Result management 3. Order management 4. Decision support 5. Electronic communication and connectivity 6. Patient support 7. Administrative processes 8. Reporting

A closer look at the intended functionality in each of these eight areas identifies some of the perceived benefits of EMRs. An electronic system would provide immediate access to key information, such as diagnoses, allergies, laboratory test results, and medications, that would improve the provider’s ability to make sound clinical decisions in a timely manner. Result manage- ment would ensure that all providers participating in the care of a patient would have quick access to new and past test results, regardless of who ordered the tests, the geographic location of the ordering provider, or when the tests were ordered or performed. Order management would include the ability to enter and store orders for prescriptions, tests, and other services in a computer-based system that would enhance leg- ibility, reduce duplication, reduce fragmentation, and improve the speed with which orders are executed. Using reminders, prompts, and alerts, computerized decision-support systems would improve compliance with best clinical practices, ensure regular screen- ings and other preventive practices, identify possible drug–drug or drug –disease interactions, and facilitate diagnoses and treatments. Electronic communication and connectivity would provide efficient and secure communication among providers and patients that would improve the continuity of care, increase the timeliness of diagnoses and treatments, and reduce the frequency of adverse events. Patients would be provided tools that give them access to their health records and interactive patient education and that would help them carry out home-monitoring and self-testing to improve control of chronic conditions. Computerized administrative tools, such as scheduling systems, would improve hospitals’ and clinics’ efficiency and provide more timely service to patients. Electronic data storage that employs uniform data standards will enable health-care providers and organizations to respond more quickly to federal, state, and private reporting requirements, including those that support patient safety and epidemiological and disease surveillance. Such data could be readily analyzed for medical audit, research, and quality assurance and could provide support for continuing medical education.

Electronic prescribing, or e-prescribing, is a specialized function within a computerized medical record system.

Electronic Medical Records In just a decade, medical documentation has transi- tioned from mostly paper records to mostly electronic records. Much of the stimulus for adoption of EMRs is the increasing evidence that current systems are not delivering sufficiently safe, high-quality, efficient, and cost-effective health care. According to HHS, 78% of office-based physicians and 59% of hospitals use a basic EMR system. EMR lies at the center of any computerized health system. The EMR is a longitudinal electronic record of patient health information gen- erated by one or more encounters in any care delivery setting. Several interchangeable terms may be used for EMR, such as electronic health record (EHR), electronic patient record (EPR), and computer-based patient record (CPR). A more comprehensive definition of EMR is provided by the 1997 Institute of Medicine report, The Computer-Based Patient Record: An Essential Technology for Health Care:

A patient record system is a type of clinical information system, which is dedicated to collecting, storing, ma- nipulating, and making available clinical information important to the delivery of patient care. The central focus of such systems is clinical data and not financial or billing information. Such systems may be limited in their scope to a single area of clinical information (e.g., dedicated to laboratory data), or they may be comprehensive and cover virtually every facet of clinical information pertinent to patient care (e.g., computer-based patient records systems).

The electronic storage of clinical information will create the potential for computer-based tools to help providers significantly enhance the quality of medical care and increase the efficiency of medical practice. These tools may include reminder systems that identify patients who are due for preventive care interventions, alerting systems that detect contraindications among prescribed medications, and coding systems that facilitate the selection of correct codes for patient encounters. The potential of such tools will not be realized, however, if the EMR is just a set of textual documents stored in a computer, that is, a “word- processed” patient chart. To support intelligent and useful tools, the EMR must have a systematic internal model of the information it contains and must support the efficient capture of clinical information in a manner consistent with this model.

Benefits of Electronic Medical Records A 2003 report by the Institute of Medicine, Key Capa- bilities of an Electronic Health Record System, identified a set of eight core health-care delivery functions that

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Chapter 1 Medicolegal Principles of Documentation | 9

such as patient records, cannot easily be shared across and sometimes within enterprises. There are signifi- cant barriers to achieving interoperability. Incredibly, there are over 1,000 EMR platforms on the market. Most of these systems are highly proprietary and may not communicate well with each other. This lack of interoperability presents a barrier to the transparent communication of health information, preventing adequate coordination of care on the small scale and obstructing population health management on a larger scale. There is no standard technical language shared between systems; hence, there is little or no integra- tion with other applications, nor is there the ability of different systems to communicate in a meaningful way with one another. Information technologies were not initially designed with interoperability in mind, so rarely are structures in place to support it. Currently used data storage systems are often proprietary, and access to these systems is difficult. Implementation of interoperable health information systems may require a high degree of technical expertise not readily available to individual providers or smaller health-care organiza- tions. Standards of interoperability are only just being developed—after many health information technology systems have already been installed and implemented. Meeting standards of operability will be an important criterion for the certification of EMR systems that are being developed at this time.

Meaningful Use In February 2009, President Obama signed into law the American Recovery and Reinvestment Act (ARRA) of 2009, which included more than $48 billion for health-care information technology for the adoption and effective use of EMR and for regional health information exchange. The Health Information Technology portion of ARRA contains information related to the Health Information Technology for Economic and Clinical Health Act ( HITECH); the HITECH Act offers financial incen- tives for health-care providers and hospitals that comply with the standards of “meaningful use.” To receive an incentive payment, providers have to show that they are “meaningfully using” their certified EMR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records. The HITECH Act imposes requirements for notification of a data breach related to unauthorized uses and disclosures of “unsecured protected health information” (PHI). These notification requirements are similar to many data breach laws at the state level related to personally identifiable financial information (e.g., banking and credit card data). Under the HITECH Act, unsecured PHI essentially means “unencrypted PHI.” In general, the Act requires that patients be notified of any unsecured breach. If a breach

Specific legislation and regulations exist that dictate the use of electronic prescribing. This is discussed in detail in Chapter 9.

Barriers to Electronic Medical Records Many perceived barriers have hampered widespread implementation of EMRs. Although numerous studies have shown that most health-care providers believe that use of EMRs will improve quality of care, reduce errors, improve quality of practice, and increase practice produc- tivity, there is resistance to adopting EMRs. A number of factors contribute to this, including well-publicized EMR failures; limited computer literacy on the part of providers; concerns over security, productivity, patient satisfaction, and unreliable technology; and the ab- sence of reputable research substantiating the benefits of EMR. Market and economic factors are a concern. Apart from the costs of hardware and software, there is a tremendous cost in staff time and revenue when switching from paper to electronic charts. Ethical and legal issues abound with concerns about safety and security of systems and the ability to protect and keep private confidential health information. There is even disagreement over who “owns” the data entered into any system as well as debate about accessibility to the data. Technical matters, such as functionality, ease of use, and customer support from vendors are other barriers. It is challenging enough to find an EMR system that works for a single-provider ambulatory care–based practice; it is another challenge altogether to find a system that will work for large institutions and serve the needs of diverse departments. Providers often complain that EMRs interfere with clinical care, making interactions more impersonal and less face-to-face while also degrading clinical documentation. Despite the huge investments that have been made in new technology, there are conflicting opinions about the value of EMRs and whether or not they will truly help improve quality of care while decreasing costs. A recent study by Medical Economics indicated that 67% of physicians are displeased with their EMR systems.

Interoperability Perhaps the biggest barrier to widespread adoption of EMR is lack of interoperability. A basic definition for interoperability is the ability of two or more systems or their components to exchange information and to use the information that has been exchanged. As it relates specifically to EMRs, the Healthcare Information and Management Systems Society (HIMSS) defines interoperability as “the ability of health information systems to work together within and across organizational boundaries in order to advance the effective delivery of health care for individuals and communities.” Without interoperability, fundamental data and information,

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may be excluded for 18 months. If a person had health insurance coverage before enrolling in a new health plan, the exclusion period may be reduced by the number of months a person was insured, as long as there were no significant breaks of 63 or more days of coverage.

Title I has additional important provisions. Pre-existing conditions do not apply to pregnancy or to a child en- rolled within 30 days of birth or adoption. Insurers are required to renew coverage to all groups regardless of the health status of any group member. Insurers may not establish any rule that discriminates based on the health status of an individual or his or her dependent, nor may they charge higher premiums or alter the level of benefits. For those individuals with their own pri- vate health insurance plan, renewability is guaranteed. Coverage cannot be terminated unless the premiums are not paid, fraud is committed against an insurer, the policy is terminated by the insured, the insured person moves outside the service area of a network plan, or the insurance is available only to members of that association and membership in the association is ended. If the insur- ance company stops selling the policy, it must offer the insured another policy it sells in the same state. Further details may be found at http://healthcare.findlaw.com/ patient-rights/hipaa-the-health-insurance-portability- and-accountability-act.html.

Electronic Health-Care Transactions Prior to implementation of HIPAA, it was estimated that about 400 different formats were being used to process health claims online. Billing and other adminis- trative procedures were inconsistent and varied among health insurers, the government, and other entities. This made it difficult for providers, hospitals, health plans, and health-care clearinghouses to process claims and perform other transactions electronically. In an effort to lower costs and improve efficiency, standards were developed to simplify the administration of health in- surance claims by requiring common formats adopted as national standards under HIPAA. The standards require that the same format is used to transmit the following health-related information: • Claims and equivalent encounter information • Claim status • Payment and remittance advice • Enrollment and disenrollment in a plan • Eligibility for a plan • Premium payment • Referral certification and authorization • Coordination of benefits

The Privacy Rule Providers have an ethical and legal obligation to safe- guard patients’ privacy. Because of the requirements of

impacts 500 patients or more, then HHS also must be notified. Notification will trigger posting the breaching entity’s name on HHS’ website. Under certain conditions, local media also will need to be notified. Furthermore, notification is triggered whether the unsecured breach occurred externally or internally.

Health Insurance Portability and Accountability Act (HIPAA) Confidentiality of medical records has always been a concern for health-care providers. Regardless of the medium of storage, confidentiality of data contained in the records will continue to be of utmost importance. With the emphasis on interoperability and the criteria that define how EMR systems must be able to exchange confidential medical information securely, a discussion of the Health Insurance Portability and Accountability Act (HIPAA, or the Act) is warranted.

Enacted by Congress in 1996 to address a number of issues affecting national health care, HIPAA is a large and complex law continually subject to revi- sions and amendments by legislative actions. The Act establishes standards, and timetables for adoption of the standards, for electronic transfers of health data, addressing growing public concern about privacy and security of personal health data. The primary goals of the standards are (1) to combat fraud and abuse; (2) to make health insurance more affordable and accessible; (3) to simplify administration of health insurance claims by requiring all entities to bill electronically using one format; (4) to give patients more control of and access to their health-care information; and (5) to protect medical records and individually identifiable medical information from unauthorized use or disclosure, es- pecially in the burgeoning electronic age.

Health Insurance Portability The Health Insurance Portability provision of the Act (Title I) improves the portability and continuity of health insurance coverage for workers and their families when they change or lose their jobs by limiting the re- strictions that a group health plan can place on benefits pertaining to a pre-existing condition. A pre-existing condition is a condition for which medical advice, diag- nosis, care, or treatment was recommended or received within the 6 months before the enrollment date for a new health insurance plan. Pre-existing conditions can be excluded from health benefits for only 12 months. A person who did not enroll during the initial or open enrollment period is considered a late enrollee, and benefits for late enrollees with pre-existing conditions

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Chapter 1 Medicolegal Principles of Documentation | 11

business associate, there must be an agreement that the PHI will be handled according to federal and state privacy laws. Additionally, a CE may disclose PHI as required by law, such as reporting child abuse to state child welfare agencies. Treatment covers a wide array of patient-related activities, including providing health care, coordinating services, referring patients, and consulting among providers. Communication between CEs may take place using any method, including oral, written, electronic mail, or facsimile, as long as “reasonable and appropriate safeguards” are used to protect the information. Payment includes activities relating to financial aspects of health care. PHI can be used for billing and claim processing to obtain reimbursement and for utilization review. Health-care operations include a wide range of administrative and management activities in which CEs engage. These include case management and patient care, risk management, legal services, credentialing, quality assessments and outcomes development, guidelines and protocol development, and training students. Sensitive PHI includes information about certain conditions or their associated treatment, such as HIV status, substance abuse, or mental health conditions. Use of PHI refers to internal use by the CE; disclosure refers to sharing of PHI for external purposes. Sensitive PHI may not be disclosed without a patient’s written authorization, except in certain circumstances, such as to a consultant who needs this information to assist in the patient’s health care.

Consent Versus Authorization Consent must be obtained from the patient at the first visit before any services are provided. Patients must sign a consent form stating that they have been notified of the practice’s privacy policy, which explains that the practice may use and disclose PHI for treatment, payment, and health-care operations. Consent needs to be obtained only once and is valid until revoked by the patient in writing. In an emergency situation, treatment may be rendered without consent, but consent should be obtained as soon as possible afterward.

For all other uses and disclosures, unless required by law, specific authorization must be obtained from the patient detailing what PHI may be disclosed, to whom it may be disclosed, and an expiration date. An authorization is needed to release PHI to life insurance companies and patients’ legal counsel. A CE may not give or sell patients’ names for commercial or marketing purposes. For example, a CE may not give or sell names of allergy sufferers to pharmaceutical companies that market allergy products.

Individual Rights Patients have the right to review and obtain a copy of their medical records, except in certain circumstances. Exceptions to the rule are psychotherapy notes, information

transmitting sensitive health information electronically, the Privacy Rule was written to protect the confidenti- ality of individually identifiable health information. The rule limits the use and disclosure of certain individually identifiable health information; gives patients the right to access their medical records; restricts most disclosures of health information to the minimum needed for the intended purpose; and establishes safeguards and restrictions regarding the use and disclosure of records for certain public responsibilities such as public health, research, and law enforcement. Under the rule, improper uses or disclosures may be subject to criminal or civil sanctions prescribed in HIPAA. Federal HIPAA regu- lations do not pre-empt any state laws that are stronger or more protective of consumers’ security and privacy.

Protected Health Information and Covered Entities PHI relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; past, present, or future payment for the provision of health care to an individual; and information that identifies or could reasonably be used to identify a protected individual. This information may be oral, electronic, paper, or any other form. Individ- ually identifiable health information includes such data as name, Social Security number, patient identification number (such as a medical record number), address, demographic data, or any other information that could reasonably allow a person to be identified.

The Privacy Rule applies only to covered entities (CEs) that transmit medical information electronically. There are three categories of CEs: (1) health-care pro- viders, such as doctors, clinics, psychologists, dentists, chiropractors, nursing homes, and pharmacies; (2) health plans, including health maintenance organizations (HMOs), health insurance companies, and government programs that pay for health care, such as Medicare, Medicaid, and the military and veterans’ health-care programs; and (3) clearinghouses that electronically transmit medical information, such as billing, claims, enrollment, or eligibility verification.

Use and Disclosure of Protected Health Information HIPAA has very prescriptive language for the use and disclosure of PHI. A CE may use or disclose PHI without patient authorization for purposes of treatment, payment, or its health-care operations. This includes dis- closures to its agents or to another CE, such as another health-care provider. Agents are business associates who perform a function for the CE, such as dictation, legal services, billing, and accounting, and are not subject to the Privacy Rule. When a CE discloses PHI to a

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health-care provider judges it to be in the patient’s best interest and as long as the patient has not restricted the release of information to that person.

Minors The Privacy Rule defers to state or other applicable laws that address the ability of a parent or guardian to obtain health information about a minor child. In most cases, the parent represents the child and has the authority to make health-care decisions about the child; however, the Privacy Rule specifies three circumstances when certain minors may obtain specified health care without parental consent: • When state or other law does not require the

consent of a parent before a minor can obtain a particular health-care service, and when the mi- nor consents to the health-care service. Example: A state law provides an adolescent the right to obtain mental health treatment without the con- sent of the parent, and the adolescent agrees to such treatment without the parent’s consent.

• When a court determines, or other law autho- rizes, someone other than the parent to make treatment decisions for a minor. Example: A court may grant authority to an adult other than the parent to make health-care decisions for the mi- nor, such as a stepparent or guardian.

• When a parent agrees to a confidential relation- ship between the minor and the physician. Exam- ple: A physician asks the parent of a 16-year-old if the physician can talk with the child confidentially about a medical condition and the parent agrees.

Even in these circumstances, the Privacy Rule defers to state or other laws that require, permit, or prohibit the CE to disclose to a parent, or provide the parent access to, a minor child’s PHI. When the laws are un- clear, a licensed health-care professional may exercise professional judgment on whether to provide or deny parental access.

When a health-care provider reasonably believes that disclosure of PHI to the personal representative who is authorized to make health-care decisions for an individual may not be in the patient’s best interest, the provider may choose not to disclose, especially in situations in which abuse, neglect, and endangerment are suspected. For example, if a physician reasonably believes that disclosing information about an incompetent older individual to the individual’s personal representative would endanger the patient, the Privacy Rule permits the physician to decline to make such disclosures.

Notice of Privacy Practices Covered entities are required to develop a privacy pro- gram detailing how their practice complies with the

compiled for lawsuits, and information that, in the opin- ion of the health-care provider, may cause harm to the patient or another individual. A reasonable, cost-based fee may be charged to cover expenses for copying and postage. If a medical summary of the record is requested, the fee should be agreed on beforehand. Patients also have the right to request an amendment or correction if they feel the record is inaccurate or incomplete and may submit a written supplement to be included in their record. If the health-care provider declines the request, the provider must do so in writing and allow the patient to submit a statement of disagreement for inclusion in the record. However, the health-care provider must allow the patient to submit a correction to be placed in the medical record. The CE also may include its own rebuttal. A health-care provider may require a patient to come into the office during normal business hours to access and inspect the record. The provider also may arrange to have someone present who can answer any patient questions or concerns.

Patients have a right to an accounting of certain PHI disclosures by a CE. The CE must be able to report who the recipient was, when the disclosure was made, and for what purpose the disclosure was made. The maximal accounting disclosure period is the 6 years preceding the request. Exceptions to this rule include disclosures for treatment, payment, or health-care operations; to the individual or their representative; pursuant to an authorization; and for national security purposes.

CEs must take reasonable steps to ensure the con- fidentiality of communications with the patient. The record should demonstrate how the patient would prefer to be contacted regarding PHI, including test results, appointment reminders, or discussions regarding his or her medical care. The patient may request to be contacted at an alternative address or telephone number.

A health-care provider may share relevant information with family, friends, or caregivers involved in a patient’s health care as long as the patient does not object and the provider feels it is in the patient’s best interest. In- formation may not be disclosed to a person not involved in the patient’s health care, if disclosure is judged to be inappropriate by the provider, or if the patient requests nondisclosure. When disclosing PHI, only the minimal information needed by that particular person should be disclosed; for example, a caregiver needs to know which medications are to be taken, what activity and dietary instructions are prescribed, and what changes in condition to report. Details about the patient’s diagnosis and prognosis may not be necessary and should not be disclosed unless requested by the patient or the patient’s personal representative. A family member or friend who is not involved in the patient’s care may be told of the patient’s condition—stable, guarded, critical—but additional information may not be disclosed unless the

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Chapter 1 Medicolegal Principles of Documentation | 13

on the Privacy Rule, to termination. If an employee does not report observed or suspected violations to a supervisor or HIPAA officer, that employee may be subject to disciplinary action for failure to report.

Although an individual may not sue anyone over a HIPAA violation, a CE may be liable for civil penalties at the state level. A CE’s failure to follow the rules and standards of the HIPAA regulations can result in civil penalties of up to $100 per violation with a cap of $25,000 per year. Criminal penalties for violations by individuals or CEs range from a $50,000 fine and up to 1 year of imprisonment for knowingly obtaining or disclosing PHI to a $250,000 fine and up to 10 years of imprisonment if the offense is committed with intent to sell, transfer, or use PHI for commercial purposes, personal gain, or malicious harm.

Security Rule Security standards were promulgated to protect elec- tronic health information systems from improper access or alteration. The confidentiality, integrity, and availability of electronic PHI must be protected when it is stored, maintained, or transmitted. CEs are required to develop and implement administrative, physical, and technical safeguards to protect against reasonably anticipated threats of loss or disclosure by implementing appropriate policies and procedures. Periodic security awareness and training of workforce members is required. Administrative safeguards must be in place to ensure the following: • Properly authorized personnel have access only to

the PHI they need to perform their job. • Prevention, detection, containment, and correc-

tion of security violations are undertaken, includ- ing sanctions against an employee who violates the privacy and security of PHI.

• A disaster recovery plan is outlined. • A process is in place to develop contracts with

business associates that ensure they will safeguard PHI appropriately.

Physical safeguards include measures that accomplish the following: • Limiting physical access to PHI systems while

ensuring properly authorized access, such as keeping computers, printers, and fax machines out of patient and high-traffic areas and installing locking doors and alarm systems.

• Providing secure access to workstations, including guidelines on use of home systems, laptops, cell phones, and other portable or handheld electronic devices.

• Establishing procedures for receipt and removal of hardware and electronic media containing PHI.

Privacy Rule. The notice must be provided to patients at or before their first encounter, or as soon as feasibly possible in an emergency situation. It must be posted in a clear and prominent location at the practice site and on its website, and a written copy should be furnished to patients at their request. Written acknowledgment of receipt of the Notice of Privacy Practices by the patient is desirable; however, a patient may refuse to sign it (often in the mistaken belief that signing it means the patient agrees with it), in which case the CE must document the reason for failure to obtain acknowledgment by the patient. Each practice should have a HIPAA privacy officer or a designated person who is knowledgeable in the standards and rules. A HIPAA attorney may be consulted in questionable matters when disclosure is a concern. Table 1-2 shows the elements that should be included in a privacy policy.

Privacy Violations and Penalties CEs should have policies and procedures in place that describe sanctions for employees who commit violations, such as accessing a medical record for any purpose outside of treatment, payment, or health-care operations; discussing PHI in public; failing to log off or leaving a computer monitor on and unsecured; or copying or compiling PHI with the intent to sell or use it for personal or financial gain. Depending on the violation, disciplinary actions may range from a letter in the employee’s file, to requiring additional training

The policy should outline the following: 1. Describe how PHI is used and disclosed. 2. State the CE’s duty to protect PHI, to provide a

notice of its privacy practices, and to abide by the terms in its notices.

3. Describe patients’ rights to: • Inspect and copy their PHI • Request a restriction of their PHI by stating the

specific restriction and to whom it applies • Request confidential communications from the

CE by alternative means or at an alternative location

• Request an amendment to their PHI • Receive an accounting of certain disclosures

the CE has made • Obtain a paper copy of the Notice of Patient

Privacy on their request • Complain to the CE or to the secretary of

HHS if they believe their privacy rights have been violated

4. Provide a point of contact for further information and for submitting complaints to: • A practice’s designated HIPAA officer • The secretary of HHS

Table 1-2 Elements of a Privacy Policy

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14 | Guide to Clinical Documentation

Practices may be audited for HIPAA compliance with or without notice. New rules and policies are frequently written, and CEs must be aware of and comply with these. HHS and CMS websites should be monitored regularly for updates.

Summary The requirements for documentation of health-care ser- vices have evolved over the past few decades. Health-care records are both medical and legal documents and serve many purposes. The complexity of documentation reflects the requirements of payers and regulatory agencies as well as the need for clear and concise communication among members of the health-care team. Just as the practice of medicine is both an art and a science, the practice of documentation is as well. Whether on paper or electronic based, records created by health-care providers must be timely and accurate and reflect good patient care, support coding and billing, and meet regulatory requirements. Completing the worksheets that follow will allow you to reinforce the content of this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

Technical safeguards must be in place that protect and control access to PHI, such as the following: • Verifying identity of a person or entity • Allowing access only to people or software pro-

grams that have access rights (e.g., using pass- words, electronic signatures)

• Auditing records and examining activity in infor- mation systems that contain or use PHI

• Protecting PHI from improper modification or destruction

• Preventing unauthorized access to PHI being transmitted over an electronic communications network (e.g., the Internet)

• Installing and regularly updating antivirus, anti-spyware, and firewall software

Summary of the Act A CE has the responsibility to develop and track a wide variety of privacy and security processes and establish policies and procedures to address all of the HIPAA standards. Employees must undergo periodic training in privacy and security rules. Risk analysis, monitoring, and testing of information systems’ security are essen- tial to ensure the confidentiality and integrity of data.

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Worksheet 1.1

Name

General and Medicolegal Principles

1. In addition to other health-care providers, list five different types or groups of people who could read

medical records you create.

2. List at least five general principles of documentation that are based on CMS guidelines.

3. Describe how to make a correction in a paper medical record.

4. Beside each of the following, indicate whether the statement is acceptable (A) or unacceptable (U)

according to generally accepted documentation guidelines.

_____ Use of either the 1995 or 1997 CMS guidelines

_____ Making a late entry in a chart or medical record

_____ Using correction fluid or tape to obliterate an entry in a record

_____ Making an entry in a record before seeing a patient

_____ Altering an entry in a medical record

_____ Stamping a record “signed but not read”

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Medical Coding and Billing

1. Indicate whether the following statements are true (T) or false (F).

_____ CPT codes reflect the level of evaluation and management services provided.

_____ The three key elements of determining the level of service are history, review of systems,

and physical examination.

_____ Time spent counseling the patient and the nature of the presenting problem are two factors that

affect the level of service provided.

_____ ICD codes indicate the reason for patient services.

_____ The ICD-10 code set has more than 155,000 codes, but it does not have the capacity to

accommodate new diagnoses and procedures.

_____ The medical record must include documentation that supports the assessment.

_____ Assignment of appropriate CPT and ICD codes that support the level of E/M services provided is

dependent only on adequate documentation of the history and physical examination.

_____ An ICD code should be as broad and encompassing as possible.

_____ There is no code for “rule out.”

_____ The complexity of medical decision-making takes into account the number of treatment options.

2. ICD codes are used to identify which of the following? Underline all that apply.

HPI Diagnosis Treatment

Physical exam findings Treating facility Symptoms

Surgical history Complaints Tests ordered

Reason for office visit Level of service Conditions

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Electronic Medical Records

1. List at least five functions that an EMR system should be able to perform.

2. Identify at least five perceived benefits of an EMR system.

3. Identify at least five potential barriers to implementing an EMR system.

4. List at least two criteria required to meet “meaningful use” standards.

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HIPAA

1. Indicate whether each statement about the Health Insurance Portability and Accountability Act is true (T)

or false (F).

_____ Establishes standards for the electronic transfer of health data.

_____ Provides health care for everyone.

_____ Limits exclusion of pre-existing medical conditions to 24 months.

_____ Gives patients more access to their medical records.

_____ Protects medical records from improper uses and disclosures.

_____ Federal HIPAA regulations pre-empt state laws.

_____ The Privacy Rule applies only to covered entities that transmit medical information electronically.

_____ Protected Health Information is data that could be used to identify an individual.

_____ Covered entities include doctors, clinics, dentists, nursing homes, chiropractors, psychologists, phar-

macies, and insurance companies.

_____ A covered entity may disclose PHI without patient authorization for purposes of treatment, pay-

ment, or its health-care operations.

_____ PHI cannot be transmitted between covered entities by e-mail.

_____ Patients are entitled to a list of everyone with whom their health-care provider has shared PHI.

_____ PHI may be disclosed to someone involved in the patient’s health care without written

authorization.

_____ The Privacy Rule allows certain minors access to specified health care, such as mental health coun-

seling, without parental consent.

_____ A Notice of Privacy Practice explains how patients’ PHI is used and disclosed.

_____ An employee cannot be terminated for violating the Privacy Rule.

_____ An individual may not sue his or her insurance company over a HIPAA violation.

_____ Criminal penalties for HIPAA violations can result in fines and imprisonment.

_____ The confidentiality, integrity, and availability of PHI need to be protected only when the PHI is trans-

mitted, not when it is stored.

_____ Employees are required to attend periodic security awareness and training.

_____ The Security Rule requires covered entities to install and regularly update antivirus, anti-spyware,

and firewall software.

_____ Physical and technical safeguards must be in place to prevent PHI from being transmitted over the

Internet.

_____ HIPAA requires a process to develop contracts with business associates that will ensure they will

safeguard PHI.

_____ HIPAA may not audit a practice for compliance without notice.

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2. From the list that follows, underline each that would be considered a covered entity according to HIPAA.

chiropractor social worker psychologist

nurse practitioner medical assistant nursing home

doctor HMO lawyer

office manager PPO Veterans Affairs (VA) hospital

Medicare Medicaid employer

hospital

3. Identify at least two conditions that are considered sensitive PHI.

4. Patients have the right to review and obtain copies of their medical records except in certain circum-

stances. List two of those circumstances.

5. Indicate by yes (Y) or no (N) whether disclosure of PHI to each specific entity in the list would require

patient authorization.

_____ Specialist/consultant

_____ Patient’s health plan

_____ Life insurance company

_____ Hospital accounting department

_____ Patient’s employer

_____ Pharmaceutical companies

_____ Reporting a gunshot wound to police

_____ Reporting names of patients with a communicable disease to a county health department

_____ Reporting suspected child abuse to a child protection agency

_____ Medical billing and coding department

_____ Friends and family involved in a patient’s health care

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Name

Abbreviations

These abbreviations were introduced in Chapter 1. Beside each, write the meaning as indicated by the context

of this chapter.

Worksheet 1.2

AMA AP, A.P., A/P

ARRA CE

CMS CP

CPR CPT

EHR E/M

EMR EPR

HHS HIMSS

HIPAA HITECH

HPI HMO

ICD-10 ICD

PMFSH PHI

ROS PRN, prn, P.R.N.

VA URI

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The Comprehensive History and Physical Examination LEARNING OUTCOMES

• Discuss the importance of a well-documented comprehensive history and physical examination. • Describe how the comprehensive history and physical examination may be adapted for various medical

disciplines and practice settings. • Identify components of a comprehensive history and physical examination. • Identify elements of the history of present illness as defined by Centers for Medicare and Medicaid

Services (CMS) guidelines. • Identify 14 systems of the physical examination as defined by CMS guidelines. • Discuss the difference between review of systems and physical examination. • Analyze sample comprehensive histories and physical examinations.

Introduction The comprehensive history and physical examination (complete H&P or H&P) is the vehicle used to doc- ument not only the patient’s medical history but also the physical examination findings, diagnoses or medical problems, diagnostic studies to be performed, and ini- tial plan of care implemented to address any problems identified. Although obtaining a thorough history and performing a detailed physical examination are critically important, the documentation of the H&P is equally important. Often this record is used as the basis for the entire course of medical management for a patient. Failure to take an adequate history or to perform a detailed physical examination—or failure to recognize important findings—may lead to inadequate care of the patient. Failure to document the comprehensive H&P adequately could have the same result.

Typically, the comprehensive H&P is obtained when a provider sees a patient for the first time in a general medical setting or when a patient is admitted to the hospital. One exception is when the patient presents with an emergent complaint and initiating treatment is a higher priority than obtaining a detailed history or performing a thorough physical examination. Almost all other types of documentation, including SOAP

(Subjective, Objective, Assessment, and Plan; discussed in Chapter 3) notes and admission H&Ps (as discussed in Chapter 10), are variations of the comprehensive H&P. Multiple providers are likely to read this document and use it to guide their management of the patient; this is one reason it is so important that the documented H&P accurately reflects the patient’s past and current health status and even documents anticipated problems. Providers in different medical disciplines usually tailor the H&P to their specialty. An H&P conducted and documented by a cardiologist, for example, will differ from an H&P completed by an orthopedist.

Components of a Comprehensive History and Physical Examination The components of a comprehensive H&P are shown in Table 2-1. The discussion in this chapter is geared to adult patients. Documentation of the newborn physical examination is presented in Chapter 4, pediatric and adolescent patients are presented in Chapter 5, and older adults in Chapter 7. Specific information that should be documented in each section follows.

Chapter 2

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24 | Guide to Clinical Documentation

History Identification The content of the identification section will vary some- what depending on where the encounter takes place. If in an office setting, this would include the patient’s name, date of birth, age, race, and gender. In a hospital setting, you would include that information as well as the medical record number, attending or referring phy- sician, and consulting physicians. You should document the patient’s reliability, that is, the patient’s ability to

provide historical information accurately. If you use an interpreter when performing the H&P, document this as well (Fig. 2-1).

Chief Complaint Document the current problem, or chief complaint (CC), for which the patient is seeking care. This is best stated in the patient’s own words, identified by quotation marks. At times, a patient may present in an outpatient setting without a specific complaint, such as

HISTORY Identification Chief Complaint (CC) History of the Present Illness (HPI) • Location • Quality • Severity • Duration • Timing • Context • Modifying factors • Associated signs and symptoms Past Medical History (PMH) • Current and past medical problems unrelated to the CC • Surgeries and other hospitalizations • Current medications, including prescription and over the

counter • Drug allergies, including how manifested • Health maintenance and immunizations Family History (FH) • Age and status of blood relatives • Medical problems of blood relatives Social History (SH) • Patient profile • Lifestyle risk factors • Employment • Education • Religion, beliefs • Cultural history • Support system • Stressors Review of Systems (ROS) • General • Eyes • Ears, nose, and throat/mouth • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal

• Neurological • Psychiatric • Endocrine • Hematologic/lymphatic • Allergic/immunologic

PHYSICAL EXAMINATION • General • Vital signs • Skin • Head, eyes, ears, nose, throat (HEENT) • Neck • Respiratory • Cardiovascular • Breast • Abdomen • Male genitalia or gynecological (breast examination

sometimes documented here) • Rectal • Musculoskeletal • Neurological

• Mental status • Cranial nerves • Motor • Cerebellum • Sensory • Reflexes

LABORATORY DATA • Results of laboratory tests, radiographs, etc.

PROBLEM LIST, ASSESSMENTS, AND DIFFERENTIAL DIAGNOSES • Most severe to least severe initially • Other problems added chronologically • Indicate if active or inactive

TREATMENT PLAN • Additional laboratory and diagnostic tests • Medical treatment • Consults • Disposition, such as admit, follow as outpatient, etc.

Table 2-1 Components of a Comprehensive History and Physical Examination1

1History and Physical Examination headings used by CMS 1997 Guidelines of Documentation for Evaluation and Management.

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Chapter 2 The Comprehensive History and Physical Examination | 25

Figure 2-1 If you use an interpreter when performing an H&P, you will need to document information about the interpreter in your facility’s EMR (e.g., Cerner) system.

Author Author's review (if needed)

Initials Date

OK Correx

ISBN #

Fig. #

Artist

B / W 4/C 2/C

Document name

Date

Check if revision

Sullivan 6662

F02_01 6662_C_F02_01.eps

AB/CO

Final Size (Width X Depth in Picas)

39p10 x 15p10

03/27/18 Editor's review

Initials Date

OK Correx2nd color PMSX

presenting to establish care or for an annual physical. Try to avoid vague terms, such as checkup, and do not document “no problems” in the CC.

History of the Present Illness or History of the Chief Complaint The history of the present illness (HPI) is a chrono- logical description of the development of the patient’s present illness from the first sign or symptom of the presenting problems. The Centers for Medicare and Medicaid Services (CMS) published the 1995 and 1997 Documentation Guidelines for Evaluation and Management of Services, identifying these elements of the HPI: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms. Several mnemonics may be used to help you remember the elements of the HPI that should be elicited; these are shown in Table 2-2. A word of caution: These mnemonics are helpful when the patient presents with a complaint of pain, but they may not be as helpful when a patient presents with a vague complaint like fatigue or when the patient presents for monitoring of a chronic condition. Your approach to obtaining and documenting the HPI will differ in these situations.

Past Medical History Use the past medical history (PMH) section to document the patient’s past and current health. Document when each condition was diagnosed, and indicate its present status, such as stable, uncontrolled, or resolved. You may subdivide information in the PMH into past medical history, past surgical history or other hospitalizations, medications, drug allergies, and health maintenance

and immunizations. Using subheadings within the PMH, as shown in Table 2-3, makes it easier to locate information and identify the change from one topic to another.

If the patient has multiple medical problems, it may be helpful to document them as an enumerated list rather than in paragraph format. If the patient has had any surgery or hospitalizations for major trauma or other reasons, be sure to include the type of operation and date of the surgery; if known, you can include the name of the doctor who performed the surgery.

You should document a medication list as part of the PMH. This includes both prescription medications and over-the-counter products, such as herbal supplements, vitamins, minerals, and dietary supplements. Be sure to include the name of the medication, the dose, how frequently it is taken, and ideally, why the patient takes the medication. Review the list of medications with the patient at every visit to ensure accuracy.

It is extremely important to document any drug allergies the patient has. You may document food allergies in this section also. You should document the specific reaction the patient experiences when the food or drug is ingested. In most settings, there will be a specific way to indicate a drug allergy, such as a special sticker affixed to the front of the patient’s chart, so that it is not overlooked. In an electronic medical record (EMR), the text may be a different color or there may be a special tab or menu bar to highlight any allergies.

It is critically important to inquire specifically about and document an allergy to latex. A patient with a latex allergy will need special equipment. You should document environmental allergies, such as an allergy to cats that results in allergic rhinitis, in the PMH. If the patient is treated regularly for allergy-related

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26 | Guide to Clinical Documentation

Mnemonic Explanation PQRST P—palliative or provocative factors

Q—quality of pain R—region affected S—severity of pain T—timing

LOCATES L—location O—onset C—character A—associated signs and symptoms T—timing E—exacerbating/relieving factors S—severity

OLD CHARTS O—onset L—location D—duration CH—character A—alleviating/aggravating R—radiation T—temporal pattern S—symptoms associated

COLDERAS C—character O—onset L—location D—duration E—exacerbating factors R—relieving factors A—associated signs and symptoms S—severity

LIQORAAA L—location I—intensity Q—quality O—onset R—radiation A—associated signs and symptoms A—alleviating factors A—aggravating factors

QFLORIDAA Q—quality F—frequency L—location O—onset R—radiation I—intensity D—duration A—alleviating/aggravating A—associated signs and symptoms

Table 2-2 History of Present Illness Mnemonics

• Past Medical History • Medical • Surgical/hospitalizations • Medications • Allergies • Health maintenance/immunizations

Table 2-3 Subheadings Used for Past Medical History

conditions, document these conditions under the heading of Medical Conditions rather than Allergies.

The health maintenance and immunization section of the PMH will vary according to the patient’s age

and gender. Chapters 5, 6, and 7 discuss documenta- tion of health maintenance activities and immuniza- tions in the pediatric, adult, and older adult patient, respectively.

Family History Typically, you should document the medical history of first-degree relatives, that is, the family history (FH) for parents, grandparents, siblings, and children. Remember that a spouse’s medical history is not considered part of the patient’s FH, although it may be applicable in situations in which a couple presents because of infertility or genetic counseling. Document the age and status (living, deceased, health status) of the first-degree relatives. If those relatives are deceased, include the age at time of death and cause of death. If the relatives are still living, document their current age and medical conditions, paying particular attention to those conditions that have a familial tendency such as cardiovascular disease, diabetes, and certain cancers, osteoporosis, and sleep apnea. Also determine whether any first-degree relatives have or had the condition with which the patient is presenting. In addition to medical conditions, inquire about any substance abuse, addic- tions, depression, or other mental health conditions of family members.

Social History One of the main goals of documenting the social history (SH) of the patient is to identify factors out- side of past or current medical conditions that may influence the patient’s overall health or behaviors that create risk factors for specific conditions. These risk factors include use of tobacco, alcohol, and drugs. If these risk factors are present, document quantity of use and how long the use has occurred. Smoking history should include number of packs per day and the number of years the patient has smoked. If the patient formerly smoked or used smokeless tobacco, you still should document the details of the tobacco use with the addition of how long it has been since the patient quit. Avoid ambiguous terms such as social drinker that do not assist you or other readers in determining whether there is a risk factor associated

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Chapter 2 The Comprehensive History and Physical Examination | 27

special events, spirituality, and taboos. Table 2-4 shows questions that you can ask as part of the religious and cultural history.

Document nutritional information in terms of type of diet the patient follows, caffeine intake, and food allergies or avoidances. If there are questions or concerns about a patient’s diet, it may be helpful to record a “typical day” or “last 24 hours” of food intake. Sedentary lifestyle is a risk factor for certain diseases, so document whether the patient exercises. If the patient exercises, include the type, frequency, and duration of exercise.

One basic consideration of a patient’s ability to ac- cess health care is whether the patient has health-care insurance or some other form of payment, such as Social Security or workers’ compensation. Although financial records generally should be kept separate from the medical records, you should document whether the patient is insured or uninsured. If uninsured, information about income or ability to self-pay becomes essential. The provision or lack of insurance will guide many health-care choices, especially related to prescribing medications. Using generic instead of brand-name medications will result in cost savings for the patient and is often medically neutral, meaning the patient should get the same benefit from generic as from brand-name medications.

Communication

• Is a translator needed? • What is your primary oral language? • What is your primary written language?

Beliefs Affecting Health and Illness

• What do you think caused your illness or condition? • How does it affect your life? • Have you seen anyone else about this problem? • If yes, who? • Have you used any home remedies for your problem? • If yes, what? • Are you willing to take prescription medications? • Are you willing to use alternative therapies, such as

herbal medicine?

Family

• Definition of family • Roles within family • Who has authority for decision-making related to your

health care?

Symbols

• Special clothing • Ritualistic and religious articles

Nutrition

• Specific food rituals • Specific food avoidances • Major foods • Preparation practices

Special Events

• Prenatal care • Death and burial rituals • Beliefs of afterlife • Willing to accept blood transfusions? • Willing to accept organ transplantation? • Organ, blood, or tissue donor?

Spirituality

• Dominant religion • Active participant? • Prayer and meditation • Special activities • Relationship between spiritual beliefs and health

practices

Taboos

• Describe any taboos that would affect health care

Table 2-4 Questions to Ask for Cultural and Religious History

with substance use. Typically, the use of illegal sub- stances is documented as drug use, but also you should determine whether the patient is taking substances prescribed for someone else or misusing prescription medication. If a risk factor is identified, be sure to include it in the problem list and assessment and plan. Age-specific SH is discussed in other chapters. Information about the patient’s sexual orientation, gender identification, marital status, and number of children is included. Documentation of the patient’s past and current employment may help identify potential occupational hazards. Include any military service and where stationed (stateside or overseas) as well as any possible exposures. If the patient has lived or traveled abroad, document locations and potential exposures, if any. It is important to document the pa- tient’s educational level and ability to read and write. If the patient speaks more than one language, you should document which language the patient prefers.

Religion and religious and cultural beliefs may have an impact on a patient’s overall health. It can be difficult to determine the difference between a re- ligious belief and a cultural belief, although typically it is not necessary to do so. Specific documentation of the religious and cultural history includes beliefs related to health and illness, family, symbols, nutrition,

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28 | Guide to Clinical Documentation

MEDICOLEGAL ALERT !

Documenting that you have counseled the patient on the risks of negative health habits and the management of chronic disease is an important part of the manage- ment of medicolegal risk. Providers have been sued for not providing patient education and counseling. One such case involved a 33-year-old woman who was obese and hypertensive and smoked. She had frequent visits to the clinic for various complaints. Routine screen- ing tests revealed marked hypercholesterolemia and an abnormal ratio of high-density lipoprotein (HDL) to low-density lipoprotein (LDL). The health-care pro- vider never counseled the patient regarding her risk for coronary artery disease. Several years later, the patient presented to an emergency room with crushing chest pain that radiated to her arms and neck. The diagnosis of myocardial infarction was confirmed, but by the time the diagnosis was made, the window of opportunity for thrombolytic therapy had closed. The patient sued the clinic and the health-care provider for malpractice. The health-care provider was found negligent for not educat- ing and counseling the patient about her risk factors for developing heart disease.

Review of Systems The review of systems (ROS) is an inventory of specific body systems designed to document any symptoms the patient may be experiencing or has experienced. Typically, you should document both positive symptoms (those the patient has experienced) and negative symptoms (those the patient denies having experienced). A positive response from a patient about any symptom should prompt you to explore all elements of that symptom just as you would for the HPI (location, quality, severity, duration, timing, context, modifying factors, and associ- ated signs and symptoms). Rather than asking whether the patient has ever experienced any of the symptoms listed, it is appropriate to limit the review to a specific time frame. That time frame might change depending on the patient’s CC and HPI; if you are seeing a patient for the first time, it is usually sufficient to ask about the past year. If the patient has been seen before, ask about the time frame since the previous visit.

Consistent with the 1995 and 1997 CMS guidelines, 14 systems are identified, and specific symptoms that should be explored in each system are included here. How many symptoms are explored within each system is up to you as indicated by the patient’s presenting complaint. 1. Constitutional: these symptoms do not fit spe-

cifically with one system but often affect the general well-being or overall status of a patient.

Specific symptoms include weight loss, weight gain, fatigue, weakness, fever, chills, and night sweats.

2. Eyes: change in vision, date of last visual examination, glasses or contact lenses, history of eye surgery, eye pain, photophobia, diplopia, spots or floaters, discharge, excessive tearing, itching, cataracts, or glaucoma.

3. Ears, nose, and mouth/throat (ENT): a. Ears: change in or loss of hearing, date of last

auditory evaluation, hearing aids, history of ear surgery, ear pain, tinnitus, drainage from the ear, history of ear infections.

b. Nose: changes in or loss of sense of smell, epistaxis, obstruction, polyps, rhinorrhea, itching, sneezing, sinus problems.

c. Mouth/throat: date of last dental examina- tion, ulcerations or other lesions of tongue or mucosa, bleeding gums, gingivitis, dentures or any dental appliances.

4. Cardiovascular (CV): chest pain, orthopnea, murmurs, palpitations, arrhythmias, dyspnea on exertion, paroxysmal nocturnal dyspnea, peripheral edema, claudication, date of last electrocardiogram or other cardiovascular studies.

5. Respiratory: dyspnea, cough, amount and color of sputum, hemoptysis, history of pneumonia, date of last chest radiograph, date and result of last tuberculosis testing.

6. Gastrointestinal (GI): abdominal pain; dysphagia; heartburn; nausea; vomiting; usual bowel habits and any change in bowel habits; use of aids such as fiber, laxatives, or stool soft- eners; melena; hematochezia; hematemesis; hemorrhoids; jaundice.

7. Genitourinary (GU): frequency, urgency, dysuria, hematuria, polyuria, incontinence, sex- ual orientation, number of partners, history of sexually transmitted infections, infertility. a. Males: hesitancy, change in urine stream,

nocturia, penile discharge, erectile dysfunction, date of last testicular examination, date of last prostate examination, date and result of last prostate-specific antigen (PSA) test.

b. Females: GU symptoms as described previously and gynecological symptoms; age at menarche; gravida, para, abortions; frequency, duration, and flow of menstrual periods; date of last menstrual period; dysmenorrhea; type of contraception used; ability to achieve orgasm; dyspareunia; vaginal dryness, menopause; breast lesions, date and type of last breast imaging; date and result of last Papanicolaou smear, date of last pelvic examination.

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Chapter 2 The Comprehensive History and Physical Examination | 29

Generally, the examination will proceed in a head-to-toe fashion. In some instances, it may be necessary to deviate from this order, such as performing an invasive com- ponent at the end of the examination or examining an area of pain last. Regardless of the order in which the examination is performed, documentation of the physical examination should follow the order that follows and in Table 2-5. Consult other textbooks for instruction on how to perform the physical examination and for a discussion on the importance of any findings; here the emphasis is on the documentation of a comprehensive physical examination. • General: age, race, gender, general appearance.

Documentation of general appearance could in- clude alertness, orientation, mood, affect, gait, how a patient sits on the examination table or chair, grooming, and the patient’s reliability to provide an adequate history. Document whether the patient is in any distress or whether the patient appears markedly older or younger than the stated age.

• Vital signs: temperature, blood pressure, pulse, respiratory rate, height, weight, and body mass index (BMI).

• Skin: presence and description of any lesions, scars, tattoos, moles, texture, turgor, temperature; hair texture, distribution pattern; nail texture, nail base angle, ridging, pitting.

• HEENT: • Head (including face): size and contour of head,

symmetry of facial features, characteristic facies, tenderness or bruits of temporal arteries.

• Eyes: conjunctivae; sclera; lids; pupil size, shape, and reactivity; extraocular movement (EOM); nystagmus; visual acuity. Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc color and size, cupping, spontaneous venous pulsations, hemorrhages, exudates, nicking, arte- riovenous crossings.

8. Musculoskeletal (MSK): arthralgias, arthritis, gout, joint swelling, trauma, limitations in range of motion (ROM), back pain. (Note that numb- ness, tingling, and weakness are typically not included in musculoskeletal but in neurological system.)

9. Integumentary: rashes, pruritus, bruising, dry- ness, skin cancer or other lesions.

10. Neurological: syncope, seizures, numbness, tin- gling, weakness, gait disturbances, coordination problems, altered sensation, alteration in mem- ory, difficulty concentrating, headaches, head trauma, or brain injury. (Headache, head trauma, or brain injury may also be listed under head, as part of Head, Eyes, Ears, Nose, Mouth/Throat, or HEENT.)

11. Psychiatric: emotional disturbances, sleep distur- bances, substance abuse disorders, hallucinations, illusions, delusions, affective or personality disor- ders, nervousness or irritability, suicidal ideation or past suicide attempts.

12. Endocrine: polyuria, polydipsia, polyphagia, tem- perature intolerance, hormone therapy, changes in hair or skin texture.

13. Hematologic/lymphatic: easy bruising, bleeding tendency, anemia, blood transfusions, thrombo- embolic disorders, lymphadenopathy.

14. Allergic/immunologic: allergic rhinitis, asthma, atopy, food allergies, immunotherapy, frequent or chronic infections, HIV status; if HIV positive, date and result of last CD4 count.

You may use standard forms or templates for gathering much of the history information, and this is certainly an acceptable, time-saving practice. However, you have an obligation to review and verify the information that the patient provides. Staff members may use the forms to enter information into an EMR. The original paper forms should be scanned into the EMR.

Physical Examination The rationale for physical examination rests on a basic assumption that there is such a thing as normality of bodily structure and function corresponding to a state of health and that departures from this norm consistently result from or correlate with specific abnormal states or disease. It is helpful to think about a “range of normal” when it comes to physical examination findings, rather than a single “normal” for every part of the examina- tion. The physical examination may confirm or refute a diagnosis suspected from the history, and by adding this information to the database, you will be able to construct a more accurate problem list. Like the history, the physical examination is structured to record both positive and negative findings in detail.

• General assessment • Vital signs: temperature, pulse, respiration, blood

pressure, height, weight, body mass index (BMI) • Skin • HEENT • Neck • Respiratory • Cardiovascular • Abdomen • Genitourinary or gynecological • Musculoskeletal • Neurological

Table 2-5 Order in Which to Document Physical Examination

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mobility of the cervix; cervical motion tender- ness, uterine or ovarian enlargement, masses, tenderness, adnexal masses or tenderness.

• Rectal: hemorrhoids, fissures, sphincter tone, masses, rectocele; if stool is present, color and consistency of stool, test stool for occult blood; prostate examination for males, noting size, uniformity, nodules, tenderness.

• Musculoskeletal: symmetry of upper and lower ex- tremities, ROM of joints, joint swelling, redness or tenderness, amputations; inspection and palpation of spine for kyphosis, lordosis, scoliosis, musculature, range of motion, muscles for spasm, or tenderness.

• Neurological: • Mental status: level of alertness; orientation to

person, time, place, and circumstances; psychiat- ric mental status or mini–mental state examina- tions if indicated.

• Cranial nerves: see Table 2-6 for details of the 12 cranial nerves and their functions.

• Motor: strength testing of upper and lower extremity muscle groups proximally and dis- tally graded on a scale of 0 to 5 as shown in Table 2-7.

• Cerebellum: Romberg test, heel to shin, finger to nose, heel-and-toe walking, rapid alternating movements.

• Ears: integrity, color, landmarks, and mobility of the tympanic membranes; tenderness, discharge, external canal, tenderness of auricles, nodules.

• Nose: symmetry, alignment of septum, nasal patency, appearance of turbinates, presence of discharge, polyps, palpation of frontal and max- illary sinuses.

• Mouth/throat: lips, teeth, gums, tongue, buccal mucosa, tonsillar size, exudate, erythema.

• Neck: ROM, cervical and clavicular lymph nodes, thyroid examination, position and mobility of the trachea.

• Respiratory: effort of breathing, breath sounds, adventitious sounds, chest wall expansion, sym- metry of breathing, diaphragmatic excursion.

• Cardiovascular: heart sounds, murmurs or extra sounds, rhythm, point of maximal impulse, peripheral edema, central and peripheral pulses, varicosities, venous hums, bruits.

• Breast: symmetry, inspection for dimpling of skin, nipple discharge, palpation for tenderness, cyst or masses, axillary nodes, gynecomastia in males.

• Abdomen: shape (flat, scaphoid, distended, obese), bowel sounds, masses, organomegaly, tenderness, inguinal nodes.

• Male genitalia or gynecological (breast examination sometimes documented here). • Male genitalia: hair distribution, nits, testes,

scrotum, penis, circumcised or uncircumcised, varicocele, masses, tenderness.

• Gynecological: External—inspection of the perineum for lesions, nits, hair distribution, areas of swelling or tenderness, labia and labial folds, Skenes and Bartholin glands, vaginal introitus; noting any discharge or cystocele if present. Internal—inspect vaginal walls and cervix for color, discharge, lesions, bleeding, atrophy; inspect cervical os for size and shape; bimanual examination for size, shape, consistency and

Number Name Major Function I Olfactory Smell II Optic Visual acuity, visual fields, fundi; afferent limb of pupillary response III, IV, VI Oculomotor, trochlear, abducens Efferent limb of pupillary response, eye movements V Trigeminal Afferent corneal reflex, facial sensation, masseter and temporalis muscle

testing by biting down VII Facial Raise eyebrows, close eyes tight, show teeth, smile or whistle, efferent

corneal reflex VIII Acoustic Hearing IX, X Glossopharyngeal and vagus Palate moves in midline, gag reflex, speech XI Spinal accessory Shoulder shrug, push head against resistance XII Hypoglossal Stick out tongue

Table 2-6 Cranial Nerves and Their Function

Grade Meaning 0 No motion or muscular contraction detected 1 Barely detectable motion 2 Active motion with gravity eliminated 3 Active motion against gravity 4 Active motion against some resistance 5 Active motion against full resistance

Table 2-7 Muscle Strength Grading

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Chapter 2 The Comprehensive History and Physical Examination | 31

Grade Meaning 0 Absent 1+ Decreased or less than normal 2+ Normal or average 3+ Brisker than usual 4+ Hyperactive with clonus

Table 2-8 Grading Reflexes• Sensory: sharp/dull discrimination, tempera- ture, stereognosis, graphesthesia, vibration, proprioception.

• Reflexes: brachioradialis, biceps, triceps, quadri- ceps (knee), and ankle graded on a scale of 0 to 4+ as shown in Table 2-8.

Based on your reading, complete the application exer- cises that follow.

Application Exercise 2.1 Read the documentation that follows and identify elements of HPI and physical examination body areas as identified by the CMS guidelines. K. J. is a 55-year-old man who presents with cough for 4 days. The cough is productive with yellow sputum. He has had sinus pressure, nasal congestion, and sore throat. He has taken over-the-counter cough medication without relief. He denies any associated fever, chills, shortness of breath, or chest tightness. He has a history of seasonal allergies and takes Zyrtec as needed when symptomatic. He has a history of hypertension. Denies smoking. No sick contacts. No family history of lung cancer. General: 55-year-old man in no acute distress. Temp 98.7. Pulse 88. Respirations 18. Blood pressure 138/80. Head normocephalic. Tympanic membranes are intact bilaterally without erythema or air/fluid levels. Nasal turbinates are engorged, clear rhinorrhea noted. Tender to palpation over frontal and maxillary sinuses. Oro- pharynx with mild erythema, no exudates. Neck without masses or lymphadenopathy. Breath sounds with coarse rhonchi both upper lobes; no crackles or wheezing. Chest is symmetrical. Heart regular, no murmurs. Abdomen soft and nontender. Extremities without clubbing or cyanosis. Cranial nerves 2 to 12 grossly intact; no focal neurological deficits.

Application Exercise 2.1 Answer K. J. is a 55-year-old man who presents with cough for 4 days (onset). The cough is productive with yellow sputum (character). He has had sinus pressure, nasal congestion, and sore throat (positive associated symptoms). He denies any associated fever, chills, shortness of breath, or chest tightness (negative associated symptoms). He has taken over-the-counter cough medication with minimal relief (alleviating factor). He has a history of seasonal allergies (medical history) and takes Zyrtec (medication) as needed when symptomatic. He has a history of hypertension (medical history). Denies any drug allergies (medical history). Denies smoking (social history). No sick contacts. No family history of lung cancer (family history).

General (1): 55-year-old man in no acute distress. Temp 98.7. Pulse 88. Respirations 18. Blood pressure 138/80 (VS 2). Head (3) normocephalic, atraumatic. Pupils equal and reactive; no conjunctival injection (eye 4). Tympanic membranes (ears 5) are intact bilaterally without erythema or air/fluid levels. Nasal turbinates are engorged, clear rhinorrhea noted. Tender to palpation over frontal and maxillary sinuses (6). Oropharynx (7) with mild erythema, no exudates. Neck (8) without masses or lymphadenopathy. Breath sounds (9) with coarse rhonchi both upper lobes; no crackles or wheezing. Heart (10) regular, no murmurs. Extremities (11) without clubbing or cyanosis. Cranial nerves 2 to 12 grossly intact; no focal neurological deficits (12).

Application Exercise 2.2 Refer to Table 1-1 in Chapter 1, and then review the note in Application Exercise 2.1. Use that information to determine what level of H&P is supported by the documentation.

Application Exercise 2.2 Answer The documentation supports a detailed history (four or more elements of the HPI; two to nine systems reviewed; one pertinent PMFSH) and detailed physical examination (affected body system [respiratory] and related or symptomatic body system [HEENT]; two to seven body areas examined; 12 to 17 bulleted items for two or more systems).

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2. Diabetes, not well controlled: review of home glucose monitoring logs shows fasting range of 150 to 180.

3. New-onset left leg swelling: no trauma, no er y- thema. Pulses are present. Concern for deep vein thrombosis (DVT).

Plan: 1. Stop ACE inhibitor. Will switch to losar tan 50 mg

once daily. 2. Check HgbA1C; continue metformin, add

glipizide 5 mg twice daily. Continue home glucose monitoring.

3. Left leg Doppler flow study. Return to clinic in 2 weeks. Assessment/Plan: 1. Cough: nonproductive and no signs or symptoms

of infectious process. Recently star ted an ACE in- hibitor, so may be side effect of medication. Stop ACE inhibitor. Will switch to losar tan 50 mg once daily.

2. Diabetes, not well controlled: review of home glu- cose monitoring logs shows fasting range of 150 to 180. Check HgbA1C; continue metformin, add glipizide 5 mg twice daily. Continue home glucose monitoring.

3. New-onset left leg swelling: no trauma, no er ythema. Pulses are present. Concern for DVT; left leg Doppler flow study.

Return to clinic in 2 weeks.

Sample Comprehensive History and Physical Examination A sample comprehensive H&P for Mr. William Jensen is shown in Figure 2-2. Mr. Jensen is a new patient to the practice of Dr. Vernon Scott, and you will follow his medical course through the documentation of his encounters with a surgeon, his admission to the hospital, surgery, hospital course, and discharge. In addition to documentation related to Mr. Jensen, you will have the opportunity to evaluate other documentation.

Summary The comprehensive history and physical examination (H&P) is one of the most important documents in the patient’s entire medical record. The H&P will vary somewhat in content at different ages and stages of life and among different medical disciplines as discussed in other chapters; however, the structure of the H&P is typically the same. Typically, you will complete the comprehensive H&P at an initial patient visit in the ambulatory setting, and documentation of subsequent visits will not be as detailed. The goal of the H&P is to

Laboratory and Diagnostic Studies Following documentation of the H&P, document the results of any studies, such as laboratory tests, radio- graphs, or other imaging studies. All results should be specifically recorded. For instance, rather than docu- menting, “the complete blood count (CBC) is normal,” document the value for each part of the CBC. This is done for several reasons. First, it presents the actual values and allows readers of the H&P to formulate their own conclusions regarding the meaning of the values. Second, it documents the baseline values that the patient has as a reference point. Third, it saves time for other readers to have the values listed rather than having to look them up.

Problem List, Assessment, and Differential Diagnosis Once you have documented all the elements of the H&P and results of diagnostic studies, you can evaluate all the information to identify the patient’s problems. Use a numbered list that includes the date of onset and whether a particular problem is active or inactive. List the most severe problems first. After the initial list is generated, new problems are listed chronologically.

Make an assessment of each current problem. This entails a brief evaluation of the problem with differential diagnosis. This is a very important component of the comprehensive H&P because it demonstrates your judgment and documents the medical decision-making that you considered regarding each problem.

Plan of Care Document any additional studies or workup needed, referrals or consultations needed, pharmacological man- agement, nonpharmacological or other management, patient education, and disposition such as “return to clinic” or “admit to the hospital.”

There are different ways that you can document the assessment and plan. Sometimes you will see assess- ment and plan documented as numbered or bulleted lists under separate headings, or you may see them together. Example 2.1 demonstrates the difference in these approaches. Either is acceptable and which is used depends largely on health-care provider pref- erence and whether documentation is paper-based or EMR-based.

EXAMPLE 2.1

Assessment: 1. Cough: nonproductive and no signs or symptoms

of infectious process. Recently star ted an angiotensin-conver ting enzyme (ACE) inhibitor, so may be side effect of medication.

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Chapter 2 The Comprehensive History and Physical Examination | 33

Comprehensive History and Physical Examination

PATIENT NAME: William R. Jensen AGE: 67

SEX: Male DOB: March 30, 19XX

CHIEF COMPLAINT: “I’ve been feeling tired and I have lost some weight.”

HISTORY OF PRESENT ILLNESS: This is a 67-year-old Caucasian male who is a new patient to this practice, having recently moved to the area. Mr. Jensen complains of “feeling tired.” He states this has been going on for several months. He first noticed this when he and his wife went on a short hike that he had previously completed without difficulty. Initially, he thought he had a mild “flu-like illness” that would account for his fatigue. The fatigue is worsened with exertional activity. Other than rest, he has not identified any alleviating factors. Mr. Jensen states that he has lost approximately 10 pounds in the past 2 months without any change in his diet or activity level. His appetite is good, and he has not intentionally decreased his food intake or avoided any type of food. Other than these two complaints, he feels well.

PAST MEDICAL HISTORY: Medical: 1. Hypertension: diagnosed at age 53 2. Dyslipidemia: diagnosed at age 58

Surgical: 1. Repair of a torn rotator cuff, right shoulder (Dr. Rodriquez, Grand Rapids, MI), age 45 2. Left inguinal herniorrhaphy (Dr. Simmons, Grand Rapids, MI) at age 38

Medications: 1. Lotensin HCT 20/12.5 once daily in the morning 2. Mevacor 20 mg once daily in the afternoon 3. Multivitamin once daily (One A Day for men) 4. Fish oil supplement twice daily, morning and evening Over-the-counter medications include occasional acetaminophen for mild headache or pain.

Allergies: Mr. Jensen states an allergy to PENICILLIN DRUGS that causes him to break out in a rash.

Health Maintenance: Last complete physical was 2 years ago. He had a screening colonoscopy at age 52 but has not had one since. He believes his PSA level was checked at the physical 2 years ago but does not recall the result. He has not had any routine blood work since his physical 2 years ago. That physical was done by Dr. Susan Maxwell in Michigan, where he previously resided.

Immunizations: Mr. Jensen did get a flu vaccine September 20XX, and his last tetanus immunization was in 20XX. He has never had the pneumonia vaccine.

FAMILY HISTORY: Father is deceased, age 74, complications of COPD and alcoholism. Mother is deceased, age 70, breast cancer. One sibling, age 71, who also has hypertension. One sibling, deceased, age 20, secondary to gunshot wound sustained in combat. Three children, alive and well, no significant medical history. Negative family history of diabetes, myocardial infarction. Positive family history of cancer (breast), hypertension/CAD, and COPD.

SOCIAL HISTORY: Mr. Jensen is married and lives in a single-story home with his wife. They have three adult children who all live nearby. Mr. Jensen is sexually active with his wife as his only partner. All sexual encounters have been heterosexual. Mr. Jensen smokes a pipe about 3 times a week and has done so for approximately 26 years. He does not use any smokeless tobacco, drink alcohol, or use any recreational drugs. He is still active and walks approximately 2 miles 4 of 7 days per week. He also bicycles and hikes occasionally. Current symptoms have affected his exercise tolerance. He does not follow a prescribed diet consistently. He limits salt intake and avoids fried foods. He eats fish twice a week, but does not eat many fresh fruits or vegetables. He estimates three or fewer servings of fruits and vegetables daily. He does not have much fiber intake. His caffeine intake includes 2–3 cups of coffee daily and 1–2 soft drinks daily. He does not have any food intolerances or food allergies. Mr. Jensen’s primary language is English. He completed an undergraduate degree and trade school. He is a retired electrician. Mr. Jensen occasionally attends a Methodist church. He states prayer is important to him, and he believes that God can heal people through prayer. He likes to include his wife in decision-making about his health care, as she is a retired nurse and has medical power of attorney for him. Mr. Jensen has a living will. He is willing to accept blood transfusions and would accept organ transplantation if needed. He is an organ donor. In addition to Medicare, he has a supplemental insurance plan that covers hospitalization and some outpatient treatment.

REVIEW OF SYSTEMS: Constitutional: Easily fatigued, feels weak. Denies any near-syncope or lightheadedness. He denies any fever or chills. No sleep disturbances.

Eyes: He has worn glasses since 1985. Denies loss of vision, double vision, or history of cataracts.

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ENT: No hearing loss, no prior ear surgery, no recent infections. Denies nasal drainage. Denies chronic sinus infections or epistaxis. Denies chronic or recurrent sore throat. No dentures or dental appliances. Last dental visit was 3 months ago.

Cardiovascular: Specifically denies chest pain, angina, and pleuritic pain. Denies any heart palpitations or irregularities in rhythm. No history of heart murmur. Denies peripheral edema and claudication. Last ECG was 2 years ago at his physical.

Respiratory: He denies SOB, DOE, or hemoptysis. Last chest x-ray was 2 years ago. He does not recall ever having testing for TB.

Gastrointestinal: He has experienced a 10-pound unintentional weight loss over the past 2 months. He denies any change in appetite, any difficulty swallowing or chewing. Some “indigestion” self-treated with liquid antacid. Rarely occurs more than twice per week and has always been relieved with antacid. His bowel movements are solid, and he has not noticed any frank blood. He states that in the past month, his stool is sometimes “tarry.” No constipation or diarrhea. No change in bowel habits. No hemorrhoids.

Genitourinary: Denies any penile discharge or erectile dysfunction. No nocturia, dribbling, incontinence, or loss of force of stream.

Musculoskeletal: Denies any joint swelling or loss of range of motion. No history of arthritis or any joint pain.

Integumentary: Denies rashes or moles. No skin lesions he is concerned about. He sees a dermatologist once a year for full skin examination.

Neurological: Denies recurrent headaches. No syncope or seizures. Denies any problems with balance or coordination.

Psychiatric: Denies any depression or mood swings. Denies any history of mental illness, drug, or alcohol abuse.

Endocrine: Denies heat or cold intolerance, excessive thirst or urination, or tremors.

Hematologic/Lymphatic: Denies easy bruising or bleeding from gums. Denies any swollen glands. No history of anemia. He has never had a blood transfusion.

Allergic/Immunologic: No asthma or atopy. Denies frequent or recurrent infections. Has never had HIV testing.

PHYSICAL EXAMINATION: General: Mr. Jensen is a well-developed, well-nourished Caucasian male who is alert and cooperative. He is a good historian and answers questions appropriately.

Vital Signs: BP 142/80; P 86 and regular, R 16 and regular; Temp 97.8 orally. His current weight is 174 pounds. Height is 5’10”. BMI is 25.

Skin: Intact, no lesions or rashes noted. Turgor is good. There is no cyanosis, pallor, or jaundice.

HEENT: Head normocephalic, atraumatic. Pupils equal and reactive to light. Wearing glasses. No AV nicking, hemorrhage, or exudate seen on fundoscopic exam. Disc margins are sharp, no cupping or edema. TMs intact bilaterally without erythema or effusion. External auditory canal is patent, no swelling. Nares patent bilaterally. No polyps noted. Nasal mucosa pink without rhinorrhea. No sinus tenderness. Oropharynx without erythema or exudate. Buccal mucosa intact without lesions. Dentition is good, and gums are pink, not inflamed.

Neck: Supple, full range of motion. No thyromegaly. No carotid bruits. No masses palpated. No tracheal deviation noted.

Respiratory: Breath sounds clear to auscultation in all lung fields. Chest wall expansion and diaphragmatic excursion symmetrical, no increased effort of breathing.

Cardiovascular: Heart regular rate and rhythm. No murmurs, gallops, or rubs. No bruit of abdominal aorta. Distal pulses are 3� and symmetrical bilaterally. No peripheral edema.

Breasts: No gynecomastia, no masses.

Abdomen: Soft, nontender. No distention, masses, or organomegaly. No dullness to percussion. Bowel sounds physiological in all four quadrants. There is no guarding or rebound noted. Genitalia: External genitalia exam reveals a circumcised male, both testes descended. No testicular or scrotal masses noted.

Rectal: Prostate nontender, not enlarged. Firm dark stool noted in rectal vault. Good sphincter tone. Stool is positive for blood.

Musculoskeletal: Fully weight-bearing. Full ROM all extremities. Well-healed surgical scars noted right anterior shoulder and left inguinal canal. No joint effusions, clubbing, cyanosis, or edema.

Neurological: Alert and oriented x 3, cooperative. Mood and affect appropriate to situation. CN II–XII grossly intact. Motor: 5/5 upper and lower extremities. Sensory intact to pinprick. DTRs 2� bilaterally and symmetrical.

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Chapter 2 The Comprehensive History and Physical Examination | 35

of life. Completing the worksheets that follow will help reinforce the material presented in this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

elicit detailed information about the patient’s medical history in order to identify risk factors, guide decisions for health maintenance, and to identify and treat con- ditions that will impact the patient’s health and quality

Laboratory Data: CBC: WBC 5,800; Hct 46; Hgb 13, differential unremarkable. Peripheral smear shows normochromic, normocytic cells Chemistry: triglycerides 178; LDL 208; total cholesterol 267; otherwise WNL. UA: negative for blood, nitrite, leukocytes. ECG: normal sinus rhythm, no ectopic beats, no ischemia. PROBLEM LIST/ASSESSMENT: 1. Fatigue. 2. Occult blood in stool. These symptoms, along with anemia and weight loss, suggestive of colon cancer. Pt will need to undergo colonoscopy for biopsy. Will call Dr. Michael Bennett’s office to schedule as soon as possible. 3. Hypertension, well controlled. 4. Dyslipidemia, fairly well controlled.

PLAN: 1. Refer to Dr. Michael Bennett for colonoscopy and biopsy. 2. Chest x-ray for baseline. 3. Continue present medications for hypertension, dyslipidemia. 4. OK to continue vitamin and fish oil supplements.

Dictated by Vernon Scott, MD

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Figure 2-2 Sample comprehensive history and physical examination.

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Name

Comprehensive H&P for D. A.

Tyler Martin, a third-year medical student on a family practice clerkship, was directed to obtain a comprehen-

sive H&P of a new patient: D. A. D. A. recently moved to your city and has never been seen at this practice. She

comes in today to establish care, and she is complaining of a cough. Following is the student’s documentation of

the comprehensive H&P. As you read it, keep in mind the requirements set forth in the 1997 Guidelines of Doc-

umentation for Evaluation and Management by CMS for information that should be included in a medical record.

Refer to the H&P to answer the questions that follow.

1. Does this document meet the CMS guidelines for documentation of a comprehensive H&P?

Why or why not?

2. Critically analyze the H&P and list any errors.

3. Did any questions come to mind that you are unable to answer after reading the H&P?

4. Are the diagnoses listed in the Assessment section reasonably supported by the history? Why or why not?

5. Did you identify other differential diagnoses or conditions that could be included in the assessment?

If so, list.

6. Is the plan reasonable based on the assessments listed? Why or why not?

Worksheet 2.1

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PATIENT NAME: D. A. AGE: 39

DOB: May 11, 19XX

CHIEF COMPLAINT: Cough

HISTORY OF PRESENT ILLNESS: D. A. presents with a persistent nonproductive cough. She denies trauma. She states the pain lasts all day long. Food and liquids do not make a difference in the cough. Pain is 6/10. Emesis, no fever.

PAST MEDICAL HISTORY: Usual childhood illnesses. UTD on immunizations. Tonsillectomy in 1980. Last physical 2 years ago and was normal.

Medications: Drixoral, Robitussin

Allergies: Penicillin. Seasonal allergies each spring and fall with mild symptoms. She does not take any medications.

Denies alcohol or drug use presently.

FAMILY HISTORY: Both parents were killed in a car accident. Father 56 and mother 49 at time of death.

SOCIAL HISTORY: Homemaker. Lives in house with spouse and children. She has a bachelor’s degree.

REVIEW OF SYMPTOMS: General: Blood pressure is 130/86; pulse is 84, respirations are 16 and nonlabored while at rest, temperature is 98.6ºF. While seen in the clinic, she coughs about every 5 minutes; the cough is dry, coarse, and nonproductive.

CV: Patient denies palpitations, edema, or swelling of the extremities, dizziness, hypertension. Pt states that she has SOB with exertion, orthopnea while going to bed that is relieved with sitting up, nocturnal dyspnea, no SOB at rest, and no chest pain.

Respiration: Pt states she has SOB with activity and when lying down at night; TB test 5 years ago was negative; no SOB at rest, cough present every 5 minutes during the day and worse at night, but denies sputum production, hemoptysis, dizziness, and asthma.

HEENT: Pt denies head or nasal congestion, headache, discharge from the nose, dizziness, otalgia, vertigo, but states she does have occasional sneezing, rhinitis, and allergy symptoms in the spring.

PHYSICAL EXAMINATION: General: White female in acute distress, coughs several times a minute. Good hygiene.

Skin: Warm and slightly moist, erythema, and moles. No scars, rashes, bruises, tattoos; hair with fine consistency, no nail pitting.

HEENT: Atraumatic, no lesions. Glasses, PEARL, EOMs intact, no conjunctival injection, no papilledema, no lesions. Ears symmetrical, no tenderness or discharge. No turbinate inflammation, no frontal or maxillary sinus tenderness. Patient has watery discharge from nose, but mucosa was pink and moist. No dentures, no exudates, good hygiene.

Neck: No masses, full ROM. Thyroid size WNL.

CV: RRR, no murmurs or rubs.

Respirations: Chest asymmetrical with respirations, no wheezes, no crackles.

Abdomen: No scars, soft, tender to palpation in upper quadrants bilaterally. No masses, no guarding, no rebound. Bowel sounds present, liver and spleen are within normal limits.

Neurological: CN II–XII intact, sensation intact, strength 5/5 and equal bilaterally. Reflexes 2+ and equal bilaterally, no cerebellar dysfunction, no limp or foot drop.

A: 1. Pneumonia 2. S/P tonsillectomy P: 1. Z-pak 250 mg as directed 2. Follow-up; call if any acute breathing problems 3. CBC, CMP

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Name

Comprehensive H&P for C.G.

A comprehensive H&P for patient C.G. is shown. C.G. is a new patient presenting to an internal medicine

office–based practice. Suzette Barnes, an experienced nurse practitioner, authored the H&P. As you read it, keep

in mind the requirements set forth in the 1997 Guidelines of Documentation for Evaluation and Management by

CMS for information that should be included in a medical record. Refer to the H&P to answer the questions

that follow.

1. Does this document meet the CMS guidelines for documentation of a comprehensive H&P?

Why or why not?

2. Critically analyze the H&P and list any errors. Identify the strengths of the H&P.

3. Did any questions come to mind that you are unable to answer after reading the H&P?

4. Are the conditions listed in the Assessment section reasonably supported by the history? Why or why not?

5. Did you identify other differential diagnoses or conditions that could be included in the assessment?

If so, list.

6. List the ICD-10 code for each of the following.

Weight loss:

Graves disease:

Migraine headache:

Anxiety:

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7. Would it be appropriate to include the ICD-10 code for Graves disease when billing for this visit? Why or

why not?

8. Is the plan reasonable based on the assessments listed? Why or why not?

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PATIENT NAME: C.G. AGE: 36

SEX: Female DOB: December 11, 19XX

DATE OF VISIT: October 9, 20XX

CHIEF COMPLAINT: “My usual doctor moved out of state, so I’m changing to this clinic.”

HISTORY OF PRESENT ILLNESS: The patient does not have any complaints at this time.

PAST MEDICAL HISTORY: Medical: Usual childhood illnesses. She has occasional migraine headaches but has not had one in about 6 months. No current or chronic illnesses. She specifically denies any HTN, lipid disorders, diabetes, or cancer. Denies hospitalizations other than for childbirth.

Surgical: Appendectomy at age 14, done as an outpatient with uneventful recovery. She does not recall the name of her surgeon. She lived in Ohio at the time of the operation. Denies major trauma requiring surgery.

Gynecological: G3, P2, AB1. Menarche age 12. Regular 28-day cycles. Took oral contraceptives for approximately 8 years; has not taken for 2 years since her husband had a vasectomy. She had a Pap smear approx. 15 months ago and was told it was normal. Has not had mammography. Patient states that she does breast self-examination “sporadically”; estimates that she does 4 to 5 self-exams per year. Medications: She takes OTC Aleve 1 or 2 tablets as needed for minor headache or muscle aches. She takes Imitrex injections as needed for migraines. Allergies: Allergic to codeine; states she gets severe nausea if she takes but denies associated rash or respiratory problems. She is allergic to shellfish and experiences hives and swelling of the lips if consumed. Health Maintenance: Last complete physical approximately 15 months ago. Pt states “everything was normal.” Patient denies ever having a blood transfusion. She is unsure of the date of her last tetanus immunization. States that she doesn’t recall having any immunizations “as an adult.” She has never had TB skin testing that she recalls; has not had an ECG. Remembers having a chest x-ray after the birth of one of her children but does not remember when that was. She is not sure why she had the chest x-ray but states she developed a fever after delivery.

FAMILY HISTORY: Father is living, age 68, and is in fair health. Mother is living, age 63 and in good health. One brother, age 39, who had stomach ulcers but is otherwise in good health. There is no history of familial diseases.

SOCIAL HISTORY: The patient is married and has 2 children, ages 8 and 5. They live in a two-story home. She has a master’s degree in economics. She teaches part-time at a community college. All family members are insured through her husband’s employer. She is fluent in English and Spanish, speaks English at home because her husband does not speak Spanish. Her only sexual partner is her husband. She previously smoked 1/2 pack of cigarettes per day for approx. 9 years; quit when she wanted to get pregnant with her first child and has not smoked since. She drinks 1 or 2 glasses of wine most days of the week and more on “special occasions.” She denies any recreational or illicit drug use. She does not have any religious preference or special practices. She sometimes practices meditation when she does yoga. She says it is important for her to be involved in decision-making regarding her health, and she would seek advice from a close friend who is a nurse. She prefers to try self-treatment with OTC and herbal products for minor illnesses but is not averse to conventional medical treatment. She does not have any food intolerances, only the shellfish allergy. She eats at least 2 servings of fruits daily and 1 to 2 servings of vegetables daily. She limits red meat to one serving per week. She avoids fried foods and tries to keep cholesterol and fat intake low. She does not follow any specific dietary guidelines. She does not have more than two caffeinated beverages a day. She is willing to accept blood transfusion or organ transplantation if needed; she is a registered donor. She does not have a living will or medical power of attorney. She states her husband would make medical decisions for her if she was unable. She exercises 4 to 5 times a week for 45 to 60 minutes, either jogging or yoga.

REVIEW OF SYMPTOMS: Constitutional: Denies fever, chills, night sweats, fatigue.

Eyes: Photophobia at times, only in association with migraine headaches. Resolves with treatment of HA. Denies any change in vision, double vision, eye pain. Unsure of date of last eye exam. Has never worn glasses or contact lenses.

ENT: Denies any change in hearing or loss of hearing. Denies ear pain, tinnitus. Denies loss of smell or change in sense of smell. No history of nasal polyps. Denies rhinorrhea, sneezing, sinus infections, epistaxis. Last dental exam about 4 months ago for general cleaning. Wisdom teeth extracted at age 19 without complications. Denies odontalgia, bleeding of gums.

CV: States “rings feel tight for a few days, then after my period everything goes back to normal.” Denies chest pain, palpitations, exercise intolerance. States that her parents were told she had a heart murmur as a child; does not recall any surgery or other intervention. Has never been told that she has a murmur as an adult.

Respirations: Denies dyspnea, cough, shortness of breath. No history of asthma.

GI: Occasional nausea associated with migraines, usually without vomiting if HA is treated early enough. She has noticed weight loss of approx. 5 lb in the past 4 to 6 weeks without any change in diet or exercise. She states that she feels like she is eating the same amount or more, saying that occasionally she will feel hungry sooner after a regular meal. Denies abdominal pain, bloating, vomiting. Bowel habits have not changed significantly, although patient states she might have 2 or 3 bowel movements some days but generally has only one. Denies diarrhea; no hemorrhoids.

(Continued)

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GU: Denies urinary urgency, frequency, hematuria, incontinence.

Gynecological: per PMH. Denies vaginal discharge, dyspareunia. No history of sexually transmitted infections. Last clinical breast exam about 15 months ago; Pap smear at that time was “normal” per pt.

MSK: Denies joint pains, loss of movement in any joints. Had fracture of the right radius and ulna at age 13, wore cast; no problems since.

Integumentary: Has noticed increased dryness of skin in the past few months. Denies associated pruritus. Has been using a moisturizing lotion with some improvement. Denies lesions or moles. Denies changes in texture of hair or nails.

Neurological: Has had migraine headaches since early 20s. Used to occur almost monthly, but after having her children says they have occurred much less frequently. She goes 6 months or longer without any HAs. When they occur, she generally wakes up early morning with the headache. If she uses the Imitrex right away, HA will resolve within an hour or 2. If she delays using Imitrex, she will usually experience nausea and photophobia. Cannot identify any specific HA triggers. Has never needed more than one dose of Imitrex to resolve HA. Denies head trauma, seizure activity.

Psychiatric: States that she sometimes feels “anxious or jumpy for no reason.” She has had 2 or 3 episodes of feeling this way in the past 2 weeks. Cannot identify any precipitating factor. States, “I just go about my business and wait for it to go away. This isn’t like me; I’m not usually a worry-wart.” She denies sleep disturbances, hallucinations, depression.

Endocrine: Denies polydipsia, polyuria. Denies heat or cold intolerance.

Hematologic/Lymphatic: Denies easy bruising or episodes of easy or prolonged bleeding. Has not noticed any enlarged lymph nodes.

Allergic/Immune: Denies allergic rhinitis, atopy.

PHYSICAL EXAMINATION: General: This is a 36-year-old Hispanic woman who appears her stated age. She is articulate and a good historian. She is alert and oriented and does not appear anxious at the present time. Grooming and affect are appropriate.

Vital Signs: T 99.1 P 84 R 20 BP 122/74. Ht 5’7” Wt 138 BMI 21.6

Skin: Good turgor, no lesions. No excessive dryness noted; no dryness or flaking of scalp or hair.

HEENT: Head normocephalic, atraumatic. PEARL bilaterally. TMs intact bilaterally without erythema or effusion. Bony landmarks well visualized. Nares patent bilaterally. No polyps. Nasal mucosa pink and moist, no rhinorrhea. Oropharnyx without tonsillar enlargement, erythema, or exudates. Buccal mucosa moist without lesions. Natural dentition, teeth stable. No gingivitis.

Neck: Supple with full ROM. No adenopathy. No thyromegaly, no masses.

CV: Heart RRR, no murmurs or gallops. PMI nondisplaced. No peripheral edema.

Respirations: Breath sounds clear all fields. Diaphragmatic excursion is symmetrical.

Abdomen: Soft, nondistended. No organomegaly or masses. Bowel sounds are present and physiological in all four quadrants.

Rectal exam: Soft brown stool in vault. Hemoccult negative. Good sphincter tone.

Back: Spine straight without scoliosis or kyphosis. No tenderness. Full ROM of spine. No CVA tenderness.

EXT: Full ROM all extremities. No joint swelling or erythema.

Neurological: Cranial nerves II to XII intact. Sensory intact. Motor is 5/5. Patellar reflexes 3/4, all others 2/4; no clonus. Negative Romberg. Gait is balanced and coordinated without ataxia.

ASSESSMENT: 1. Unintentional 5 lb weight loss. R/O thyroid disorder; with anxiety and hyperreflexia, Graves disease is likely. 2. Migraine headaches, stable.

PLAN: 1. CBC, CMP, TSH, T3, T4, UA. Consider endocrinology referral depending on lab results. 2. Continue Imitrex injectable, 0.6 mg Subcutaneous PRN migraine HA. Rx given. 3. Return in 1 week to review lab results. 4. Schedule well-woman exam within next month.

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Name

Abbreviations

These abbreviations were introduced in Chapter 2. Beside each, write the meaning as indicated by the content

of this chapter.

Worksheet 2.3

ACE

CBC

CMS

EMR

ENT

HDL

HPI

LDL

PMH

ROM

SOAP

BMI

DVT

EOM

H&P

HEENT

MSK

PSA

ROS

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SOAP Notes LEARNING OUTCOMES

• Define the Subjective, Objective, Assessment, and Plan components of a SOAP note. • Organize pertinent positive and negative aspects of the history in the Subjective portion of the note. • Organize pertinent positive and negative findings of the physical examination in the Objective portion

of the note. • Generate the Assessment portion by analyzing information from the Subjective and Objective portions

of the note. • Document assessments using terminology consistent with International Classification of Diseases,

10th Revision (ICD-10) codes. • Identify components of patient management that should be documented in the Plan section of the note. • Evaluate sample SOAP notes, and complete worksheets related to each section of a note.

Introduction Although it is necessary to perform and document a comprehensive history and physical examination (H&P) at the beginning of the patient–provider relationship, it is unnecessary and too time consuming to document that level of detail at subsequent visits. It is unlikely that much of the history information would change if the patient has frequent visits for monitoring chronic conditions. Also, the comprehensive H&P may be documented at times when the patient does not present with a specific complaint. At other times, visits are problem focused, either for monitoring of chronic conditions or for evaluation of a new problem. One way to document problem-focused visits is with a SOAP note. SOAP stands for Subjective, Objective, Assessment, and Plan. The SOAP format is used in many different practice settings. It is important to understand that sections of the SOAP note are interrelated. The completeness and accuracy of the history (subjective information) will help guide what you look for when performing a problem-specific physical examination (objective information) and formulating a list of possible causes, also known as differential diagnoses (DDX). Together, the subjective and objective information should lead you to, and should support, the assessment or most likely diagnosis. Once you have made an assessment, you can establish a plan of care.

Subjective It is beyond the scope of this book to address interviewing techniques and interpersonal skills; you should employ your best communication techniques when interviewing the patient and obtaining the history that will make up the Subjective portion of the SOAP note. (Several reference texts that deal with medical interviewing are listed in the bibliography.) Although all parts of a SOAP note are important, your ability to take and record an accurate medical history is one of the most important tasks to be mastered in medicine. In 1947, Platt claimed that, in most cases, the diagnosis can be made with the history alone. In 1975, Hampton and colleagues attempted to evaluate the relative contribu- tions of history taking, the physical examination, and laboratory tests in making medical diagnoses. Nearly 20 years later, Peterson and colleagues undertook a study to quantitate the relative contributions of the history, physical examination, and laboratory investigation in making medical diagnoses. They found that history taking led to the final diagnosis in 61 of 80 patients, or 76% of encounters. More recent studies have validated these findings. With all the technological advances and the availability of diagnostic testing, the temptation is to minimize or abbreviate the history taking, but doing so may jeopardize your ability to reach an accurate diagnosis. Obtaining an adequate history often will

Chapter 3

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46 | Guide to Clinical Documentation

take the most time during a patient encounter, but this is time well spent. Likewise, the attention given to documenting the Subjective portion of a SOAP note is equally important.

The elements of the comprehensive H&P that are identified as subjective information are as follows: • Chief complaint (CC) • History of present illness (HPI) • Problem-focused or pertinent past medical

history (PMH) • Problem-focused or pertinent family history (FH) • Problem-focused or pertinent social history (SH) • Any specialized history related to the chief

complaint (for instance, obstetrical and gyneco- logical history for a female patient who presents with irregular menses)

• Problem-focused or pertinent review of systems (ROS)

Subjective information is what the “subject” or patient tells you. As discussed in Chapter 2, the chief complaint (CC) is best recorded in the patient’s own words, but, in some electronic medical records (EMRs), you may have to choose the CC from a list, as shown in Figure 3-1. Sometimes, subjective information is obtained from someone other than the patient. A spouse or family member, a caregiver, and members of the health-care team all could offer subjective information. Subjective information can be gathered from prior medical records. If someone other than the patient provides the history, document who provided the history and his or her relationship to the patient.

On occasion, you might want to use quotation marks to identify information as a direct quote from the patient and to indicate that you have recorded the patient’s exact words. This is particularly so when recording the CC if the patient is describing something (such as pain) or if the patient does not answer a question to your satisfaction.

Figure 3-1 The CC is best recorded in the patient’s own words, but, in some EMRs, you may have to choose the CC from a list.

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Chapter 3 SOAP Notes | 47

For instance, when asked if she takes any medication, a patient responds, “Yes, I take a little red pill for my blood pressure.” You could guess what that little red pill may be, but for the sake of accuracy, it would be better to document this information using the patient’s own words (patient takes “a little red pill” for hypertension). The use of quotation marks lets other readers know that the information within the marks is not your paraphrase or restatement of something the patient told you but the actual words from the patient. Notice that the word “hypertension” was substituted for “blood pressure.” It is acceptable to do this because the patient is stating a fact and you are translating the lay term into an accepted and more specific medical term that will have consistent meaning to others who will read the note.

One of the most challenging aspects of documenting the subjective information is determining what elements of the history are pertinent to the presenting complaint. It takes years of practicing medicine to understand the importance of certain associated signs and symptoms and how they relate to the CC. Many conditions have a certain pattern of presentation. A man having a myo- cardial infarction is likely to present with chest pain or pressure, sometimes radiating to the neck, jaw, or arm; nausea, dyspnea, and diaphoresis are often part of the symptom complex of infarction. Not only should you ask about all these signs and symptoms as you gather the medical history, but also you should document the absence or presence of each of these signs and symptoms. Some findings from the history will support or suggest one diagnosis more than another. These findings are “pertinent positives” because their presence is pertinent to the specific problem. The absence of other findings, called “pertinent negatives,” likewise may suggest a cer- tain diagnosis and help rule out other diagnoses because of their absence. Consider the history of a 22-year-old man who presents with low-grade fever and right lower quadrant abdominal pain. The DDX of acute appendi- citis should come to mind. Patients with this condition typically present with anorexia, or loss of appetite. If this man has anorexia, that is a pertinent positive finding and would support the DDX of appendicitis. If he states that he is hungry and wants to know how soon he can eat, the absence of anorexia is a pertinent negative, and, although it does not rule out appendicitis, it makes that condition less likely. When documenting certain elements of the history, such as associated signs and symptoms, it is helpful to list all pertinent positives together and then to list the pertinent negatives. Pattern recognition is one way that you can make a diagnosis. Documenting the pertinent positives and negatives in the patient’s history often will help other health-care providers recognize the pattern of the condition the patient is exhibiting.

Your documentation of pertinent positives and nega- tives should be detailed enough to narrow the DDX and

eventually lead to the most likely diagnosis. Try to anticipate what information other readers want to know, such as the presence or absence of certain findings, and be sure that the information is included in your documentation. For example, if an 18-month-old child presents with a history of fever and a rash, and the parent states that the child is inconsolable, the diagnosis of meningitis should come to mind. Your documentation should reflect that you considered this diagnosis; therefore, it should include the presence or absence of symptoms that are associated with meningitis. Lethargy is one such symptom; therefore, if the child is attentive and looking around the room and interactive with his environment, these are pertinent negatives in the child’s history that lead you away from the diagnosis of meningitis or make it less likely.

Analyzing Documentation There are at least two ways to develop documentation skills: (1) practice, practice, and practice, and (2) crit- ically analyze documentation. This text gives you the opportunity to do both. Read the subjective information documented in the following two examples, and then answer the questions.

EXAMPLE 3.1

CC: “my left knee hur ts” S: This 42-year-old man presents with complaint of left knee pain. He injured his knee while playing softball. His pain has gradually worsened over the past week. He has not noticed any swelling. He denies any numbness below the knee. He has not had any prior knee surgery. He is allergic to penicillin. He denies tobacco use. He works full-time in computer sales.

Based on the information in this note, answer the following questions:

1. How long has the patient had left knee pain? 2. Has he tried anything to relieve the pain? 3. What per tinent positives and negatives are docu-

mented? Are there any other per tinent elements of the patient’s histor y that should have been documented?

4. Does the patient have any chronic medical conditions?

5. Has the patient had any surgery? 6. Does the patient take any medications?

As you can see, this entry did not allow you to answer these questions. However, all of the information should be part of the history related to the patient’s CC of knee pain and should be documented as subjective information. This information is important to anyone who may be involved in the patient’s care. Read Example 3.2, and then answer these same questions.

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48 | Guide to Clinical Documentation

Objective The elements of the comprehensive H&P that are identified as objective information are as follows:

• Vital signs (VS) • A general assessment of the patient • Physical examination findings • Results from laboratory or diagnostic studies

Objective information is what you or others can observe. Typically, you would document it in the order listed previously. You may document VS on a flow sheet or some other place in the chart, especially if the patient is hospitalized. If the VS are recorded elsewhere, it is a good idea to record them again in the Objective section. Recording the specific readings of the vital signs is preferred over “VS stable” or “VS within normal limits (WNL).” It is easier and more convenient for others who will read the note to see the actual numbers, and this allows them to make their own interpretation of the VS.

A general assessment is not always included in a note in an office-based encounter but is very helpful in certain settings or with certain more serious or urgent CCs. Document a general assessment in a way that helps identify the patient and paints a picture of the patient’s overall presentation and status. Identifying information typically documented includes the patient’s age and gender and sometimes the patient’s race. Con- sider two patients who present to an urgent care center with shortness of breath. The general assessment for the first patient is documented as “a 28-year-old man who is cyanotic, using accessory muscles and gasping for breath.” General assessment of the second patient is documented as “a 28-year-old man sitting comfortably who is acyanotic and has no tachypnea or increased respiratory effort and is able to speak in complete sentences.” The approach to these two patients will be different based on the observations made about each patient. Although most providers automatically make this assessment mentally, it is good practice to document it specifically, especially in settings where patients are seen based on the acuity of their condition and not the order in which they arrive.

Just as it is challenging to know how much history to obtain and document in the Subjective portion, it also may be a challenge to obtain and document the physical examination and other objective information. The objective information should flow logically from the subjective and should reflect your DDX just as the subjective does. Physical examination is usually taught in a system-based manner, and this may help you to know how much examination to do, which systems to examine, and how much examination to

EXAMPLE 3.2

CC: “my left knee hur ts” S: This 42-year-old man presents with complaint of left knee pain. He originally injured his left knee about a month ago while playing softball. He states that he slid into a base and his foot caught against the bag, which twisted his knee. In the past week, the pain has gradu- ally worsened. He describes the pain as “a deep ache.” He has not noted any swelling of the knee. The pain is worse when he stands for more than half an hour at a time and when he walks and goes up stairs. The patient has taken ibuprofen 400 mg occasionally for the pain, with some relief. He denies any numbness or tingling of the extremity or previous injury to the knee. He does not have any chronic medical problems and specifically denies having a history of hyper tension or ulcers. He has never had surgery. He does not take any medications on a regular basis. He is allergic to penicillin, which causes a rash. He is married, has two children, and is employed full-time in computer sales. He denies any tobacco use, drinks “a few beers a week,” and denies drug use.

The note in Example 3.2 is longer than the one in Example 3.1. It is also more thorough and helps answer the questions a reader was not able to answer after reading the note in Example 3.1. The note in Example 3.2 does a better job of documenting the required elements of the HPI as well as pertinent positives and negatives. Notice also the use of quotation marks (“my left knee hurts” and “a few beers a week”) that indicates verbatim responses from the patient. There will be times when you want to include the patient’s exact words in your documentation; ideally, you should ask follow-up questions in order to determine exactly how often the patient consumes alcohol and how much he consumes. This would give you a better idea of whether the patient has any health risks associated with alcohol use.

MEDICOLEGAL ALERT !

When a condition or symptom involves any part of the body that involves laterality, specify the area of concern and do so consistently. In Example 3.2, the patient com- plained of left knee pain. Verify that you document left knee when you are referring to history and report left knee findings from the physical examination. Most con- ditions involving an extremity warrant examination of and comparison to the contralateral extremity. Even one discrepancy in use of left or right could raise doubts as to which side is being examined or treated. Malpractice lawyers will look for such discrepancies and will be sure to point them out, which might damage your credibility.

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Chapter 3 SOAP Notes | 49

positive and negative findings from the physical examination. The history of a patient who presents with a sore throat includes the pertinent positives of sudden onset, fever, pain with swallowing, and a muffled voice, prompting the DDX of streptococcal pharyngitis. On physical examination, you would expect to see tonsillar enlargement, erythema of the tonsils and pharynx, and possibly exudates. Presence of any of these findings is considered a pertinent positive and makes the diagnosis of streptococcal pharyngitis more likely than if the findings were not there. The absence of any of these findings would be a pertinent negative.

Formats for Documenting Objective Information Two formats are commonly used for documenting the Objective portion of a SOAP note. Example 3.3 shows the narrative format, and Example 3.4 shows the system-heading format. Either format is acceptable; which one is used is determined by the facility and may be influenced by the method of documenting, whether paper-based or computer-based. Some health-care providers prefer the system-heading format because the use of headings makes it easier to find specific information. Instead of reading the entire Objective section, a reader can go quickly and easily to the system related to the CC. If using the system-heading format, omit the heading for any system not examined. It is not necessary to include the heading and then document “not examined” or “not pertinent.”

EXAMPLE 3.3 NARRATIVE FORMAT

The patient is a 42-year-old man who is aler t and coop- erative. His temperature is 98.2, respirations 20, pulse is 88, and BP is 126/64. The head is normocephalic and atraumatic. The pupils are equal, round, and react to light. The neck is supple without any masses. The spine is straight without any tenderness over the ver tebral bodies. The upper extremities show full ROM of all joints. Left leg is without any swelling or deformity. There is tenderness to palpation at the medial aspect of the left knee; no obvious dislocation of the patella. The anterior drawer sign is negative. There is full ROM of the left hip and knee without crepitance. McMurray test is positive at the left medial aspect. The right leg is without any swelling or deformity. There is no tender- ness to palpation. Full ROM of the right hip and knee. Negative anterior drawer sign and negative McMurray. Muscle strength 5/5 bilaterally. Cranial nerves II to XII are grossly intact, and there are no focal neurological deficits. Straight leg raise is negative bilaterally. Patellar and ankle reflexes are 2+ bilaterally.

document. Some CCs will be associated with a specific system; back pain, for instance, is associated with the musculoskeletal system, so the physical examination would focus on the musculoskeletal system. Because the musculoskeletal and the neurological systems are interrelated and either could be the source of the back pain, you also would perform and document a neuro- logical examination. Use the DDX of a complaint to help determine which systems are examined. A 34-year- old woman presenting with abdominal pain has a DDX that includes appendicitis, cholecystitis, ovarian cyst, sexually transmitted disease, ectopic pregnancy, and so on. Your documentation should indicate that both the gastrointestinal (GI) and the gynecological (GYN) systems were examined. If DDX arising from systems other than GI and GYN are considered, then you also should examine the associated system(s) or body area(s).

Typically, you would perform the physical exam- ination in a head-to-toe format. You can modify this approach as needed, omitting systems that do not need to be examined in a problem-focused encounter or saving the examination of a system for last because of discomfort for the patient. Regardless of the order in which the examination is performed, you should document it in head-to-toe order. The suggested order of documenting a physical examination is shown in Table 3-1. You should be aware that there are vari- ations of this format. Some providers will document the respiratory and cardiac examinations under the heading CHEST. Some will document pulses under the heading of EXTREMITIES rather than in the cardiovascular system. These are acceptable variations. The content of the documentation is usually far more important than the format.

Just as there are pertinent positive and negative find- ings from the history, typically there will be pertinent

Table 3-1 Order in Which to Document Objective Information for SOAP Note

• Vital signs: temperature, respiration, blood pressure, height, weight, body mass index (BMI)

• General assessment • Skin • Head, Eyes, Ears, Nose, Throat (HEENT) • Neck • Chest • Abdomen • Genitourinary or gynecological • Extremities • Musculoskeletal • Neurological

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having the test result specifically documented because this will give them the opportunity to make their own interpretation of the results and save the time of having to look up results that may be documented elsewhere in the medical record.

If you plan to order diagnostic tests but do not have the results at the time you are documenting, this is usually documented as part of the plan instead of an objective finding. This is because there are no results to observe or document yet. Consider the 42-year-old man presented in Example 3.2 who presents with left knee pain. After gathering the problem-specific history, or subjective information, you perform the problem-specific physical examination (objective information). You decide to order an x-ray of the knee. If you cannot perform the x-ray on site, the patient will have to go to an outpatient facility. Dr. al Zahid, the radiologist at the facility, typically telephones with the results of the x-ray, so you ask the patient to return to your office after the x-ray is taken. When you get the results, you document “x-ray of the left knee is negative for any fracture or other acute findings per Dr. al Zahid.” If you perform the x-ray on site, or if the patient returns with the x-rays taken at another facility, you would view the films and document the interpretation as your own (e.g., “I personally reviewed the x-rays of the left knee and do not see any fracture or other acute findings”).

Interventions Done During the Visit You should document any interventions done during the visit in the Objective section. Suppose the patient described in Example 3.2 is seen at 5:30 p.m. You cannot take x-rays on site, and the outpatient facility where he would have an x-ray done is closed. In the meantime, you provide a knee immobilizer and instruct the patient on crutch walking. Document these interventions in the Objective section of the note. Obtaining an x-ray is part of your plan, which is discussed later in this chapter. If the patient were instructed to return tomorrow after x-rays are taken, that would also be part of the plan.

Use Application Exercise 3.1 to test your skills in differentiating between content that belongs in the Subjective part of a note and information that belongs in the Objective part of the note.

EXAMPLE 3.4 SYSTEMS-HEADINGS FORMAT

General: The patient is a 42-year-old man who is aler t and cooperative. His temperature is 98.2, respirations 20, pulse is 88, and BP is 126/64.

HEENT: The head is normocephalic and atraumatic. The pupils are equal, round, and react to light.

Neck: The neck is supple without any masses. Musculoskeletal: The spine is straight without any

tenderness over the ver tebral bodies. The upper extremities show full ROM of all joints. Left leg is without any swelling or deformity. There is tenderness to palpation at the medial aspect of the left knee; no obvious dislocation of the patella. The anterior drawer sign is negative. There is full ROM of the left hip and knee without crepitance. McMurray test is positive at the left medial aspect. The right leg is without any swelling or deformity. There is no tenderness to palpation. Full ROM of the right hip and knee. Negative anterior drawer sign and negative McMurray. Muscle strength 5/5 bilaterally.

Neurological: Cranial nerves II to XII are grossly intact, and there are no focal neurological deficits. Straight leg raise is negative bilaterally. Patellar and ankle reflexes are 2+ bilaterally.

Documenting Diagnostic Test Results You should document the results of laboratory or other diagnostic tests in the Objective portion of a SOAP note. Tests that may be ordered for a 34-year-old woman who presents with abdominal pain include a complete blood count (CBC), basic metabolic panel (BMP), urinalysis (UA), urine pregnancy test, and abdominal ultrasound. The results of these studies would generally follow the documentation of the physical examination.

Give the name of the test first, then the result (e.g., CBC shows a white blood cell (WBC) of 5.8, hemoglobin (Hgb) of 11, and hematocrit (Hct) of 34). If all the results are within normal limits, you may document as “the CBC is WNL.” If one component of a panel of tests is abnormal, but the rest are normal, you could document “BMP shows a potassium of 5.2; otherwise, the results are WNL.” Other readers will appreciate

Application Exercise 3.1 Indicate which is subjective (S) or objective (O). ____ The right hand is swollen. ____ There is no tenderness to palpation of the right knee. ____ My left arm feels numb and has a tingling sensation.

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Chapter 3 SOAP Notes | 51

____ Patient is hard of hearing. ____ No respiratory distress is noted. ____ Patient denies allergies to any medication.

Application Exercise 3.1 Answer The right hand is swollen. Objective There is no tenderness to palpation of the right knee. Objective My left arm feels numb and has a tingling sensation. Subjective Patient is hard of hearing. Objective No respiratory distress is noted. Objective Patient denies allergies to any medication. Subjective

Application Exercise 3.2 The patient complains of experiencing shortness of breath over the past 3 days. It started gradually and is progressively worsening. The shortness of breath is worse with any activity. He has also noted swelling of his feet and ankles. The patient has had an occasional nonproductive cough. He specifically denies any chest pain or hemoptysis. He has not had any fever or chills, congestion, or sore throat. PMH is significant for myocardial infarction 5 years ago. He takes carvedilol daily. He denies smoking or other tobacco use. Based on the subjective information documented previously, examination of which two systems should be

documented in the Objective portion of the SOAP note?

List at least three specific components that should be examined in each of these two systems.

Application Exercise 3.2 Answer Based on the subjective information documented previously, examination of which two systems should be documented in the Objective portion of the SOAP note?

1. Respiratory 2. Cardiovascular

List at least three specific components that should be examined in each of these two systems.

1. Respiratory: effort, rate, breath sounds 2. Cardiovascular: heart rate, heart rhythm, peripheral pulses, peripheral edema, jugular venous distention

In Application Exercise 3.2, read the subjective documentation, and answer the questions that follow.

Adhering to the recommended head-to-toe order of documenting the physical examination in the Objec- tive portion of a SOAP note, indicate in Application

Exercise 3.3 the order in which each finding should be documented.

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dysuria, and the DDX of urinary tract infection (UTI) is considered. A pertinent positive finding from the physical examination is mild suprapubic tenderness. UA shows 2+ leukocytes, trace nitrites, and microscopic hematuria, but it is otherwise negative. The UA is suggestive of a UTI but does not confirm the diagnosis. Other conditions considered in the DDX could be causing the patient’s symptoms and the UA findings. If the result of a urine culture is positive, then the diagnosis of a UTI can be made definitively. There are times when you will not be able to make a definitive diagnosis at a single visit, such as when additional testing is indicated but not readily available and must be scheduled for a later time. If a definitive diagnosis has not been reached, a symptom may be listed as the assessment. Example 3.5 compares symptoms and some of the possible definitive diagnoses and shows ICD-10 codes for each.

EXAMPLE 3.5

Symptom ICD-10 Definitive Diagnosis

ICD-10

Dysuria R30.0 Urinar y tract infection

N39.0

Right knee pain

M25.562 Osteoar thritis of right knee

M17.31

Left ear pain H60.12 Acute otitis media, left ear

H65.02

Right lower quadrant pain

R10.31 Acute appendicitis

K35.80

Fatigue R53.8 Anemia D64.9

Assessment Careful analysis and interpretation of the subjective and objective data should lead to a logical assessment. Impression, diagnosis, and assessment are terms used in- terchangeably. Upon reading the CC, you can formulate a DDX. Table 3-2 shows examples of DDX for four common complaints.

As subjective and objective data are assimilated, you can refine the list of DDX. Laboratory and other diag- nostic studies may help confirm a suspected diagnosis, although such studies are not always necessary to reach a final diagnosis, as in the case of sinusitis. A definitive (or final) diagnosis is based on diagnostic evidence. For example, a patient may present to the clinic complaining of

Application Exercise 3.3 ________ The neck is supple without adenopathy or masses. ________ BP 120/72, P 80, R 16, T 97.8. ________ Faint crackles are noted at the base of the lungs bilaterally. ________ The patient is a 72-year-old man who appears his stated age and is in no acute distress. ________ No hemorrhages or AV nicking seen on funduscopic examination. ________ The abdomen is soft and nondistended. Bowel sounds are present in all four quadrants. ________ The heart rhythm is irregularly irregular.

Application Exercise 3.3 Answer 4 The neck is supple without adenopathy or masses. 1 BP 120/72, P 80, R 16, T 97.8. 5 Faint crackles are noted at the base of the lungs bilaterally. 2 The patient is a 72-year-old man who appears his stated age and is in no acute distress. 3 No hemorrhages or AV nicking seen on funduscopic examination. 7 The abdomen is soft and nondistended. Bowel sounds are present in all four quadrants. 6 The heart rhythm is irregularly irregular.

Table 3-2 Examples of Differential Diagnoses Based on Chief Complaint

Chief Complaint Differential Diagnoses Headache Tension headache, migraine

headache, cervical myofasciitis, sinusitis, cerebrovascular accident, space-occupying lesion

Eye pain Trauma, conjunctivitis, corneal abrasion, sinusitis, orbital cellulitis, glaucoma, keratitis, ocular migraine, hordeolum

Vaginal discharge Candidiasis, bacterial vaginosis, trichomonas, chlamydia, gonorrhea

Diarrhea Infection, irritable bowel syndrome, food intolerance/ allergy, ulcerative colitis, antibiotic induced

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Chapter 3 SOAP Notes | 53

Differential Diagnosis When you cannot determine a definitive diagnosis, then document a list of DDX, reflecting conditions that are being considered and that may require further workup. It is beyond the scope of this text to address the process of developing and refining DDX. Although generating a list of DDX is a basic skill that you can learn with practice, it takes extensive clinical training and a wealth of clinical experience to develop the higher-order critical thinking skills needed to synthe- size and analyze data in order to refine and continually narrow the DDX and arrive at a logical most likely or definitive diagnosis. There is certainly truth in the axiom, “if it is never considered, it will never be diag- nosed”; therefore, you must be able to generate DDX for every problem with which a patient presents. It is one thing to know that a patient has a herniated disk with radicular symptoms and then to consult a medical textbook about the particulars of that condition. It is another thing altogether to have a patient in front of you who presents with back pain or numbness in the leg and to have to go through the process of investi- gating a symptom and arriving at a certain diagnosis. That process is a complex and multifaceted one, and this text makes no attempt to teach clinical reasoning or medical decision-making but aims to present only a brief discussion of the importance of documentation that reflects the subjective and objective data that you gathered about a symptom or specific problem, doc- umenting an assessment or assessments that reflect analysis of such data and support a plan of care. It may be helpful for you as a student or novice health-care provider to consult symptom-based books as a starting point to developing DDX (see the Bibliography for specific references).

When documenting the DDX, list in order of most likely to least likely. The list does not need to be all- inclusive but should demonstrate thoughtful analysis of the available data. This allows other readers to follow your reasoning and should demonstrate when addi- tional workup is warranted. In some practice settings, laboratory and imaging services are readily available; having the results of diagnostic studies at the time of the encounter may establish a definitive diagnosis. When these services are not available, documentation of the plan should reflect which studies are needed and how the results will guide you to formulate a treatment plan or management strategy for the patient. Example 3.7 illustrates documenting the assessment when a definitive diagnosis has not been reached and includes the DDX. Note that an ICD-10 code is listed only for the presenting symptom, and no codes are listed for the DDX. This is to prevent a diagnosis being inadvertently added to a patient’s record or submitting billing for a diagnosis that has not yet been proven.

The first assessment listed should usually correlate with the presenting complaint. As you uncover other diagnoses, list them in order of importance or impact on the CC. Remember to list any comorbidities that may influence the patient’s medical course. Refer to Example 3.6.

EXAMPLE 3.6

S: This patient complains of experiencing an aching, occasionally sharp pain in the right lower leg over the past 2 days. He noticed an open sore on the right leg this morning. He has felt feverish and slightly nauseated since last night. He rates the pain severity as 5/10 at rest; standing worsens the pain to 8/10. He has not had any relief with Tylenol or elevation of leg. Measurement of the fasting blood sugars range from 200 to 275, and 2-hour postprandial blood sugars range from 250 to 325. Last HgbA1C done 3 months ago and was 8.3. PMH: Significant for type 2 diabetes and HTN. Medications: Metformin 1,000 mg BID; Glyburide 5 mg

BID; Lisinopril 20 mg daily. Allergies: NKDA Social: 30-pack-year history of cigarette smoking; quit

2 years ago. Denies alcohol or drug use. O: General assessment: 68-year-old man who is alert

and oriented but looks mildly distressed. VS: BP 156/94; P 94; R 20; and T 97.0. Wt 235, Ht 70” Heart: RRR without murmur. Lungs: Adventitious breath sounds throughout all lung fields. Extremities: There is a 2-cm superficial ulceration on the

right lower leg proximal to the lateral malleolus with 4-cm area of surrounding erythema and increased warmth. Dorsalis pedis pulses are 1+ and equal. There is decreased sensation from the midcalf to the toes bilaterally.

A: Ulcer right lower leg S81.801 Cellulitis r ight lower leg L03.115 Type 2 diabetes, poorly controlled E11.65 Diabetic neuropathy E11.40 Essential hyper tension I10

MEDICOLEGAL ALERT !

Be careful that you do not document or code a diag- nosis until it has been proven definitively. Documenting an unproven diagnosis may adversely affect the patient’s present and future health care. It could also result in in- appropriate coding.

The ulcer and cellulitis of the right lower extremity represent the presenting complaint, whereas the poorly controlled type 2 diabetes, neuropathy, and hypertension are comorbid conditions that may affect his overall medical course and outcome.

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Application Exercise 3.4 List several DDX for the following CCs:

Neck pain Low back pain Cough Epistaxis Shortness of breath

Application Exercise 3.4 Answer Neck pain Muscle strain, torticollis, spinal stenosis Low back pain Herniated disk, ankylosing spondylitis, musculoskeletal strain Cough Asthma, bronchitis, pneumonia, COPD Epistaxis URI, trauma, bleeding disorder Shortness of breath Pulmonary embolism, heart failure, pneumonia

DDX: otitis externa, otitis media, eustachian tube dysfunction

A: Left calf pain (M79.662) DDX: deep vein thrombosis, cellulitis, muscle strain

Test your skills related to generating the DDX in Application Exercise 3.4.

Plan This section of the SOAP note includes documentation of diagnostic studies that will be obtained, referral to other health-care providers, therapeutic interventions, education, disposition of the patient, and any planned follow-up visits. Each problem or diagnosis documented in the Assessment portion should be addressed in the Plan portion. The details of the Plan portion should follow an orderly manner, which may vary depending on your practice setting. One suggested format is the following: 1. Additional laboratory and diagnostic tests. 2. Consults: referrals to specialists, therapists

(physical, occupational), counselors, or other professionals.

3. Therapeutic modalities: pharmacological and nonpharmacological management.

4. Health promotion and disease prevention: ad- dress risk factors as appropriate and consider age-appropriate preventive health screening and immunizations.

5. Patient education: explanations and advice given to patients and family members.

6. Disposition/follow-up instructions: when the patient is to return, the conditions or symptoms that indicate the patient should return sooner, and when to go to another facility such as an emergency department, urgent care center, specialist, or therapist.

Laboratory and Diagnostic Tests Additional testing may be necessary to establish or evaluate a condition. Laboratory and imaging studies, physiological assessments, and other evaluations not performed during the patient encounter are components of the Plan section. Some tests, such as magnetic reso- nance imaging (MRI), may require prior authorization from the patient’s insurance carrier. Documentation should establish the rationale for any testing ordered by the health-care provider.

Consults Specialist consultations or referral to other health-care providers may be needed to establish a definitive diag- nosis, to evaluate a known condition, or for treatment of an acute or chronic condition. For example, you might refer a patient with right lower quadrant (RLQ) pain to

EXAMPLE 3.7

A: Left lower quadrant abdominal pain (R10.32) DDX: diver ticulitis, ovarian cyst, ureterolithiasis A: Right great toe pain (M79.674) DDX: gout, ar thritis, fracture A: Right ear pain (H92.01)

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Chapter 3 SOAP Notes | 55

control over their health and its determinants, and thereby improve their health.” Health promotion and disease prevention programs often address social determinants of health, which influence modifiable risk behaviors. Modifiable risk behaviors include, for example, tobacco use, poor eating habits, and lack of physical activity, which contribute to the development of chronic disease. Disease prevention focuses on strategies to reduce the risk of developing chronic diseases and other morbidities. Another aspect of disease prevention is through routine screening tests. Documentation of immunization status is an important part of disease prevention. Specific aspects of health promotion and disease prevention are addressed for pregnant women, pediatrics and adolescents, adults, and older adults in Chapters 4 through 7, respectively.

Patient Education Education is such an important aspect of health pro- motion and disease prevention that it deserves special mention. When a patient has a positive encounter with a health-care provider, it is often because the provider took time to explain the diagnosis and treatment plan. Most patients want to know what is causing their symptoms, what their treatment options are, the expected outcome, and why or when to return to the office. When you prescribe or recommend medication, you should inform the patient about the benefits and risks and potential side effects. Educating patients about their condition or disease enables them to take control of their health. Patient satisfaction surveys report that patient education is considered an important indicator of the quality of care received. Encourage your patients to be active participants in their own health care, which often improves compliance with treatment.

a surgeon to be evaluated for possible appendicitis. Often you will refer pregnant women to an obstetrics-gynecology (OB/GYN) specialist for obstetric management. You could refer a pediatric patient with speech difficulties to a speech therapist for evaluation and management. You may refer a patient to a physical therapist for evaluation and treatment of injuries and musculoskeletal problems. Many insurance companies require an authorization for such consults. A copy of the medical record pertaining to the complaint is frequently reviewed to establish the “medical necessity” of the consultation. Thorough doc- umentation is critical in justifying the need for service.

Therapeutic Modalities Pharmacological Treatment Frequently you will prescribe medications for patients to treat illnesses, conditions, or symptoms. You must document specific details of the prescribed medication, such as name, dose, route of administration, frequency of administration, and duration. Prescription writing is covered in Chapter 9. If you recommend an over-the-counter (OTC) medication, then you would document the same details listed earlier for prescription medications. When prescribing or recommending a medication for use as needed (PRN), your documentation should indicate what condition or symptom the medication is intended for, for example, diphenhydramine 25 mg 1–2 tablets every 6 hours PRN itching.

Documentation also should address any change in current medications, such as adjusting the dosage or frequency or discontinuing a medication. For example, Mrs. Aguilar has been taking amoxicillin for sinusitis for the past 5 days and is not improving. When issuing a new prescription for cephalexin, also document that she was instructed to discontinue the amoxicillin.

Nonpharmacological Treatment A wide variety of nonpharmacological treatment modalities may be included in the patient’s overall management plan. Often you may recommend behavioral and lifestyle changes, such as smoking cessation, weight loss, exercise, relaxation techniques, and dietary adjustments. Specific instructions may include “drink plenty of fluids and rest” or “rest, ice, compression, and elevation” (RICE) of an injured extremity. Dressing changes, activity modifica- tion, and monitoring parameters (e.g., blood pressure and blood glucose levels) are all nonpharmacological treatment modalities. Patient education is an important adjunct to therapeutic recommendations.

Health Promotion and Disease Prevention The World Health Organization defines health pro- motion as “the process of enabling people to increase

MEDICOLEGAL ALERT !

Documentation of patient education is not only good medical practice, but also it may prevent a lawsuit. This applies to medications prescribed, tests performed, consents obtained, warnings, recommendations, patient education, and follow-up instructions.

Printed handouts are valuable tools to reinforce instructions given verbally to patients. There are many resources available on just about any condition that you might encounter. Some books have tear-out sheets to give to patients. Others have pages you can photocopy. There are software programs and websites that allow you to customize and personalize handouts with your office logo and information. Pharmaceutical companies may provide patient education materials; for example, a

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56 | Guide to Clinical Documentation

or you may instruct the patient to go to an urgent care center or emergency department if a serious problem develops.

You can determine the time frame for routine follow-up by how soon you would expect a patient to exhibit a response to the treatment initiated. If a patient has been taking antibiotics for otitis media, you would expect the patient to improve within 48 to 72 hours; therefore, documentation would include “follow up if not improved in 2 to 3 days.” Consider potential complications that could occur; in the case of otitis media, meningitis is a rare but serious complication. Document the specific symptoms that indicate the need for evaluation, such as persistent fever, headache, vomiting, or neck stiffness. This is especially important for pediatric patients and in situations in which the patient’s condition could deteriorate rapidly. Failure to document your instructions to the patient is considered failure to provide those instructions.

Follow-up visits are an opportune time to ask patients whether they have any questions about what was discussed at previous visits. Encouragement and reinforcement will promote patient understanding of the condition and compliance with treatment, which, in turn, may lead to

company that makes insulin will offer handouts related to care of a diabetic patient, such as dietary information, logbooks for patients to record blood glucose readings, and other educational materials for patients and their families. Documenting which handouts and materials you give the patient may prompt you to inquire about the patient’s understanding of the material at a sub- sequent visit. Simply providing written material to the patient does not meet your obligation to provide education. You should determine the patient’s ability to read and understand the material before distributing written materials. Figure 3-2 is an example of a patient education handout.

Follow-Up Instructions It is important to document follow-up instructions at every patient visit, regardless of the reason for the visit. Specific information that you should document includes when the patient should return for follow-up, signs or symptoms that could indicate worsening of the patient’s condition, and what to do if those signs or symptoms develop. You may advise the patient to call your office for further instructions. You may determine that the patient should return to the office for re-evaluation,

Figure 3-2 Sleep hygiene guide.

Sleep Hygiene Guide

• Take a hot bath to raise your temperature for 30 minutes within 2 hours of bedtime. A hot drink may also help you.

• Daily exercise at least 6 hours before bedtime is best.

• Consider purchasing a “noisemaker” to block out background noise. It plays soothing sounds of “white noise” or raindrops, ocean waves, etc.

• Limit naps to 10 or 15 minutes during the day. Short naps can be beneficial.

• Listen to tapes of relaxing music or soothing natural sounds if you have trouble falling asleep.

• Jot down problems and set aside a time the next day to focus on them.

• Eliminate intrusive sound and light from your bedroom so you won’t be awakened accidentally.

• Sleep in a cool, well-ventilated room (ideal temperature 64° to 66°F).

• Limit caffeine use to no more than 3 cups consumed before 10 a.m.

• Do not smoke after 7 p.m., or quit smoking altogether. Nicotine has the same effect as caffeine on sleep.

• Use alcohol lightly. Alcohol can fragment sleep, especially the second half of your sleeping period.

• Avoid heavy meals and heavy spices in the evening. If you have regurgitation problems, raising the head of the bed should help.

• Develop a bedtime ritual. Bedtime reading, unrelated to work, may help relax you.

• If you wake in the night, don’t try too hard to fall asleep; rather, focus on the pleasant sensations of relaxation.

• Avoid unfamiliar sleep environments.

• Quality of sleep is important. Too much time in bed can decrease the quality of the next night’s sleep.

• Limit the bedroom to sleep and relaxation. Don’t use it as a work area.

Author Author's review (if needed)

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Figure 3-3 One example of a complete office note in an EMR from the HPI through the physical examination of each body system to the assessment and plan.

Author Author's review (if needed)

Initials Date

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58 | Guide to Clinical Documentation

documentation of pertinent positives and pertinent negatives helps to demonstrate a pattern. Obtaining and documenting subjective information is often the most time-consuming part of the encounter but often will lead to the diagnosis. The subjective infor- mation guides what physical examination should be done. When documenting the objective information, painting a picture of the patient’s presentation by documenting a general assessment helps to provide context for the encounter. Taken together, the subjec- tive and objective information should lead to logical assessments, impressions, or differential diagnoses. Once the final assessment is determined, the plan documents what actions you will take to treat the patient’s condition. To reinforce the content of this chapter, please complete the worksheets that follow. Worksheets 3.4, 3.5, and 3.6 include SOAP notes for encounters in different practice settings, written by various providers. Compare and contrast these notes and how they are adapted for the chief complaint and setting of care. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

a more favorable outcome. Numerous studies indicate that communication between clinician and patient is the single most effective predictor of patient adherence to a treatment plan. If you use effective communication skills, the patient will become an educated participant in the treatment, thereby increasing the likelihood of compliance. The concept of effective clinician-patient communication is a necessity, not an option.

Figure 3-3 shows a complete office note in an EMR from the HPI through the physical examination of each body system to the assessment and plan.

Summary SOAP notes provide a format to document problem-focused encounters when a comprehensive H&P is not needed. The SOAP note is adaptable to different practice set- tings. It takes years of clinical practice to develop the judgment necessary to determine how much history to obtain and how much physical examination to complete and document. Consider that much of the process of making a diagnosis is pattern recognition;

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Name

SOAP Note Components: Subjective and Objective

A 45-year-old woman presents with a chief complaint of right hand pain.

1. List the seven cardinal aspects of the history of present illness that should be documented in the Subjec-

tive information.

2. List several pertinent aspects of the PMH that should be documented.

3. What information about the patient’s social history would be important to document?

4. A patient presents with a chief complaint of back pain. Listed here are several statements from the HPI

for a chief complaint of back pain. Number them in the order that they should appear in the Subjective

paragraph.

_____ Pertinent negative associated symptom: The patient denies any trauma.

_____ Aggravating factor : The pain is worse after standing or walking for more than 20 minutes.

_____ Onset: The pain started 3 days ago after moving some heavy furniture.

_____ Pertinent positive associated symptom: The patient has had a tingling sensation in the right

buttock area.

_____ Severity: The pain is described as a dull ache and is rated as a 4/10.

5. Which of the following would be documented as subjective information? Underline all that apply.

vital signs history obtained from spouse medications

x-ray report family history CBC results

physical examination findings review of systems onset of chief complaint

Worksheet 3.1

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6. Number the following sentences in the order they should appear in the Objective paragraph, according to

“head-to-toe” order.

_____ The abdomen is soft and nondistended.

_____ The oropharynx shows some erythema of the posterior pharyngeal wall but no exudates.

_____ Auscultation of the lungs does not reveal any abnormal breath sounds.

_____ The neck is supple with full range of motion, and there are no signs of meningeal irritation.

_____ The skin is warm to touch and without cyanosis.

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Name

SOAP Note Components: Assessment and Plan

This SOAP note was written by a nurse practitioner working in pediatrics.

S: This 6-year-old boy presents with a sore throat x 3 days. His mother states that he has had a fever of 101.5,

seems to have difficulty swallowing, and complains of a headache. His appetite is decreased. He has a runny

nose with clear discharge. Denies cough, abdominal pain, vomiting, or diarrhea. There are no known expo-

sures to communicable diseases. Tylenol helps the fever and sore throat “a little.” PMH is negative. Meds:

none. NKDA. The child is generally healthy. He is up to date on immunizations.

O: T 100.8 (oral), P 98, R 20, BP 100/64

General: WDWN boy in NAD.

Skin: No rash

HEENT: Canals and TMs are unremarkable. Nasal mucosa is slightly congested with pink turbinates and clear

discharge. Pharynx shows 3+ injected tonsils with scant exudates.

NECK: Supple. Tender, moderately enlarged tonsillar lymph nodes.

HEART: Rate 98 and regular without murmur.

LUNGS: Clear to auscultation. No adventitious sounds. Nonlabored breathing.

Abdomen: Soft, nondistended. Mildly tender throughout but without guarding or rebound. No organomegaly or

masses. Bowel sounds are normoactive.

1. Based on the subjective and objective information, what assessment or differential diagnoses come to

mind?

2. What tests, if any, would you order? How might the results affect your DDX?

3. Write a plan for this patient including all of the components discussed in the text.

Worksheet 3.2

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Name

SOAP Note Components: Plan

1. Which of the following would be documented in the Plan portion? Underline all that apply.

physical examination findings

information from medical records

patient education

CBC results

R/O ankle fracture

laboratory and x-ray orders

vital signs

recommended OTC medications

follow-up instructions

review of systems

referrals

2. Number the following sentences in the suggested order they should appear in the Plan portion.

_____Discussed the DDX with patient.

_____Follow-up in 2 weeks.

_____CT of chest if symptoms not resolved within 2 weeks.

_____Refer to respiratory for pulmonary function testing.

_____Go to the ED if shortness of breath worsens despite albuterol.

_____Handout on monitoring peak expiratory flow readings given and explained.

_____Albuterol inhaler 1–2 puffs every 4–6 hours PRN wheezing.

Worksheet 3.3

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Name

SOAP Note Analysis: A. W.

Here is a SOAP note for patient A. W. who presented to an urgent care center with complaints of nausea and

vomiting. She has not been seen at this urgent care before. The SOAP note was written by Jason Wilson, a

physician assistant student who is on a rotation at the urgent care center. Please read the note and answer the

questions that follow.

Worksheet 3.4

CC: “I have been nauseated and throwing up.”

HPI: Pt is a 41-year-old who presents with a 1-day hx of nausea. Nausea began yesterday morning, and she began vomiting in the afternoon. Since onset of vomiting, she is unable to keep down solid food or liquids. She initially vomited 2–3 times per hour and then less frequently. Pt denies diarrhea or constipation. Pt denies recent travel or camping trip. Pt states a coworker was sick last week with an unknown illness.

PMH: Lactose intolerance. No meds

ROS: + N/V, negative SOB, palpitations

O: General: A&O x 3, in moderate distress, lying on exam table with emesis basin

Vital Signs: BP 116/62, P 104, R 20, T 101

CV: RRR, no murmur

Respiratory: No wheezing or crackles Abd: + bowel sounds x 4. Negative Murphy and McBurney

A: Food poisoning, R/O hepatitis A, R/O GERD

P: IV of normal saline fluid bolus CBC, BMP Ibuprofen

Author Author's review (if needed)

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1. Analyze the Subjective portion of the note. List additional information that should be included in the

documentation.

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2. Analyze the Objective portion of the note. List additional information that should be included in the

documentation.

3. Is the assessment supported by the subjective and objective information? Why or why not?

4. Did you consider differential diagnoses other than the ones documented? If so, list.

5. What condition/symptom/diagnosis would be most appropriate to document for this visit? Can you find

an ICD-10 code for it?

6. Does the plan correspond to the assessment? Why or why not?

7. Did you consider other interventions that could be included in the plan? If so, list.

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Name

SOAP Note Analysis: R. K.

R. K. is a patient who presented to an emergency department. Jacqueline Mitchell, the resident working in the

ED, saw him and wrote this SOAP note. Please read it and answer the questions that follow.

Worksheet 3.5

CC: “My lips and tongue swelled up and I thought I was going to die.”

HPI: Pt states that 6 hours ago he had sudden onset of swelling in his lips and tongue. He had a hard time breathing. His wife urged him to take some Benadryl and he took one 25 mg tablet. After approximately 1 hour, the swelling began to resolve, and the difficulty breathing also resolved. At this time, he is not experiencing any difficulty breathing, and he feels that the swelling is almost completely gone. He specifically denies any chest pain or heart racing associated with this episode. He did not notice any itching of the skin or hives. He had one similar episode many years ago after eating shrimp, and has avoided all shellfish since that time. He is certain that he has not ingested shellfish in the past 48 hours.

PMH: HTN for at least 10 years. He was in good control on HCTZ only until recently. He saw his primary care provider earlier this week and was given a prescription for a new medication. The prescription is labeled as lisinopril 10 mg. He has taken four doses of lisinopril but never developed any symptoms until today. No hx of asthma or urticaria. Denies any immune disorders. Has never had any surgery.

Medications: HCTZ 12.5 mg once daily for “many years.” Lisinopril 10 mg daily started in the past 4 days.

Allergies: No drug allergies that he is aware of. States an allergy to shellfish, which caused swelling of the lips and a rash.

FAMILY Hx: No hx of angioedema. Mother had HTN; deceased at age 72 from CVA. Otherwise noncontributory.

SOCIAL Hx: Denies tobacco use. He drinks 3–4 beers per week. Denies drug use.

O: General: Pleasant 47-year-old male sitting in chair talking comfortably. No respiratory difficulty or cyanosis. Does not appear anxious at this time.

Vital Signs: BP 138/86; P 98; R 22; T 98.9; pulse oximetry 98% on room air.

Skin: Intact without lesions, no urticaria.

HEENT: Head normocephalic. No noticeable swelling of lips. Oropharynx without erythema. No swelling of the tongue or uvula.

Neck: Supple, full ROM. No tracheal deviation.

Chest: Heart RRR. No murmurs. Breath sounds clear in all fields without wheezing. Good air movement throughout without increased effort of breathing.

Ext: No swelling of hands or feet.

A: 1. Angioedema, resolved, probably secondary to lisinopril. 2. HTN, stable at present.

P: 1. Stop lisinopril and do not take again. 2. Follow up with PCP regarding medication change, continue HCTZ as directed. 3. Return to ED immediately if any recurrence of symptoms. 4. May take Benadryl 25–50 mg every 6 hours PRN itching or return of swelling of lips or tongue.

Author Author's review (if needed)

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1. Analyze the Subjective portion of the note. List additional information that should be included in the

documentation.

2. Analyze the Objective portion of the note. List additional information that should be included in the

documentation.

3. Is the assessment supported by the subjective and objective information? Why or why not?

4. Did you consider differential diagnoses other than the ones documented? If so, list.

5. What condition/symptom/diagnosis would be most appropriate to document for this visit? Can you find

an ICD-10 code for it?

6. Does the plan correspond to the assessment? Why or why not?

7. Did you consider other interventions that could be included in the plan? If so, list.

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Name

SOAP Note Analysis: C.F.

The SOAP note on page 71 is for patient C. F. who presented to an internal medicine office with complaints of

abdominal pain. She has been seen at this office before, although not by this provider. She is seen by Malia Yazzi,

Physician Assistant, who writes the SOAP note. Please read the note and answer the questions that follow.

1. Analyze the Subjective portion of the note. List additional information that should be included in the

documentation.

2. Analyze the Objective portion of the note. List additional information that should be included in the

documentation.

3. Is the assessment supported by the subjective and objective information? Why or why not?

4. Did you consider differential diagnoses other than the ones documented? If so, list.

5. What condition/symptom/diagnosis would be most appropriate to document for this visit? Can you find

an ICD-10 code for it?

Worksheet 3.6

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6. Does the plan correspond to the assessment? Why or why not?

7. Did you consider other interventions that could be included in the plan? If so, list.

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CC: “My stomach has been hurting, and it is getting worse.”

HPI: CF complains of LLQ abdominal pain that began 3 days ago. She describes the pain as “crampy” and intermittent, although she says the pain never entirely goes away but waxes and wanes. At the onset, the pain was 2/10; however, it has progressively worsened every day, and she now rates the pain as an 8/10. The pain does not radiate but stays in the LLQ. The pain does not seem to be related to food intake. She has not identified any aggravating factors. She did take some Tums yesterday, 2 tablets, but did not experience any relief or change in the pain. She has felt warm and has had chills, but has not actually taken her temperature. She has had some nausea that started yesterday, but has not vomited. Pt has had chronic constipation for “at least 10 years” and says that she normally takes a laxative 2–3 times a week to stimulate bowel movements; in the past 24 hours, she has had 4–5 loose stools. She specifically denies any blood in the stool.

PMH: No hx of GI problems in the past other than the chronic constipation, no colitis, ulcers, malabsorption problems. No abdominal surgery; only surgical history is a breast biopsy 5 years ago that was negative. No previous episodes of similar symptoms. Menopausal for about 12 years.

Medications: Ex-lax 2–3 times weekly for “at least 10 years.” Takes a multivitamin once daily. No regular prescription meds.

Allergies: Sulfa drugs, which she says gives her a rash.

FH: No hx of colon or other cancer.

SOCIAL: Denies tobacco use; occasional cocktail “on special occasions” but does not consume alcohol on a regular basis. Married, cares for husband who has dementia.

O: General: 64-year-old obese black woman sitting on table. Alert and conversant; febrile, looks mildly ill but NAD. Good historian.

VS: BP 132/78; P 99.2; R 18; T 100.8

Heart: RRR

Lungs: Clear to auscultation

Abd: Soft, obese, nondistended. No surgical scars. Tenderness to palpation localized to LLQ. No guarding or rebound. No masses or organomegaly. Bowel sounds present throughout. No tympany to percussion.

Rectal: Soft dark stool in rectal vault. No masses. Stool negative for occult blood.

Flat and upright abdominal plain films do not show any air fluid levels and no free air in the peritoneum, per my interpretation. Blood work pending.

A: 1. LLQ pain, probably acute diverticulitis, R/O partial bowel obstruction. 2. Chronic constipation.

P: 1. CBC, CMP, UA 2. Stop Ex-lax for now. 3. Discussed further workup; pt unable to stay overnight in hospital as she is sole caretaker for husband. Since patient is not vomiting, will manage as outpatient but discussed with pt the potential complications of ruptured diverticula, possible widespread infection requiring surgery, and need for her to contact me immediately if she worsens at all. If condition worsens, will likely need hospitalization with urgent CT scan of abdomen, surgical consult. 4. Metronidazole 500 mg PO BID x 14 days + ciprofloxacin extended release 500 mg by mouth once daily for 14 days. Pt educated on reason for double-antibiotic therapy. 5. Acetaminophen 500 to 1,000 mg every 4 hours prn pain or fever. Pt offered narcotic analgesic but declined. 6. Promethazine 25 mg tablet PO every 6 hours prn N/V; advised on possible drowsiness, should not drive or operate machinery while taking. 7. Return for follow-up in 48 hours. If any increased pain or vomiting and unable to keep down antibiotics, call office immediately. 8. Clear liquid diet until nausea and pain resolve, then slowly advance diet. 9. Will need routine colonoscopy when asymptomatic because she has not had one in approx. 10 years. 10. Patient given handout on diverticular disease, questions answered.

Author Author's review (if needed)

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Writing a SOAP Note From Narrative

Now that you have evaluated some sample SOAP notes, it is time to apply what you have learned. This work-

sheet will give you the opportunity to take subjective and objective data gathered during a patient encounter

and document as a SOAP note. The subjective data are presented in narrative form. Pertinent positive and

negative findings from the physical examination are given for you to incorporate into the Objective portion of

the note. With this information, you should be able to formulate and document an assessment and a plan. Crit-

ically analyze the information given, and determine how much of it needs to be documented. Document the

encounter as you would for one that takes place in a primary care outpatient setting.

M. J. is a 57-year-old woman who comes in because of “leaking urine.” This has been an occasional problem

for the past 6 months or so, mostly occurring when she coughs or sneezes. In the past week, the symptom is

worse, and she says, “I just can’t seem to hold my urine.” She has to go to the bathroom every 1 to 2 hours

and only voids a small amount each time. She gets up at least once during the night to void. She reports feeling

an urgency to void but does not have any burning or pain when she voids. The sense of urgency is great; she

states, “I have to go immediately or I will wet myself.” She has been limiting her fluid intake to see if it would

help with the symptoms and has quit drinking coffee and tea; this hasn’t seemed to make a difference. The

problem is frustrating, and she has “to plan my day around where bathrooms are located. If I’m at the mall or

the grocery store or waiting for my kids at soccer practice, I know where every bathroom is located.” M. J. is

very self-conscious about the problem and says, “It is embarrassing to walk around with a wet spot on my

pants. I’ve started wearing those pads that old women wear; I can’t stand the thought I might have to start

wearing diapers!” She has noticed her urine is dark with a strong odor. She thinks this is due to limiting her fluid

intake. She has not had any fever or chills and has not had any nausea or vomiting.

M. J. is generally healthy and does not have any active or chronic diseases. She takes a multivitamin every day

and calcium supplements as recommended by her OB/GYN. She is allergic to penicillin, which causes a rash

and swelling in her lips. She last saw her OB/GYN about 9 months ago for her routine checkup and didn’t

mention this because it happened infrequently at the time and she thought it was all “normal since I’m getting

older.” She entered menopause at age 49 and says she hasn’t really had any problems with menopausal symp-

toms. Her checkup with the OB/GYN did not reveal any abnormal findings. M. J. is married and has 5 children;

all births were vaginal deliveries without complications. She has never had any abdominal or gynecological sur-

gery. She had surgery for “chronic sinus infections” at age 28 and carpal tunnel surgery on the right hand at age

46. Her only sexual partner is her husband. Intercourse is pleasurable as long as she uses a lubricant. She does

not discuss her problem with her husband because she is embarrassed about it.

M. J.’s parents are both deceased. Her father died at age 61 of a heart attack. Her mother had diabetes,

diagnosed around the age of 45. She died from complications of colon cancer. M. J. has three siblings: an older

Worksheet 3.7

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brother with high blood pressure, one sister who has diabetes, and a younger brother who does not have any

health conditions she is aware of.

M. J. is a life-long nonsmoker. She drinks wine 2–3 times a month. She has never used any illicit drugs. She typi-

cally drinks 2–3 cups of coffee per day and 3–4 glasses of tea daily, but she has cut out those beverages for the

past week to see whether it improved her symptoms. Her daily exercise consists of taking her dogs for a walk,

although she admits that she has not done that for the past week as she “can’t even make it around the block

without feeling the urge to urinate and having to go. I’d have to wear a diaper to make it through my usual route.”

(The only positive findings from the ROS are those above. As you write the SOAP note, consider whether you need to

include any pertinent negatives in your documentation.)

M. J. is a well-developed, well-nourished woman who appears her stated age. She is not in any distress at the

present time. She is alert and cooperative and interactive and answers questions appropriately.

Vital signs recorded in the chart are as follows:

BP 124/72, P 86, RR 18, T 99.1, height: 5’8”, weight: 174 lb

The physical examination (excluding the pelvic exam) is essentially normal. (Write in findings for a “normal

examination” that you would conduct related to the patient’s problem.) Here are the findings for the pelvic and

rectal examinations:

Pelvic: atrophic changes noted of the external genitalia, but no erythema, lesions, or masses. Vaginal mucosa pale,

loss of rugae consistent with age-related changes. Cervix parous, pale, without discharge. Uterus anterior,

midline, smooth, and not enlarged. No adnexal tenderness. Rectovaginal wall intact. Positive dribbling of urine

with cough and bearing down.

Rectal: no perirectal lesions or fissures. External rectal sphincter tone intact; rectal vault with soft brown stool;

without masses.

A voided urine sample is obtained and results of a diagnostic test strip are as follows:

Color: dark amber

Clarity: clear

Specific gravity: 1.022

pH: 6.5

Negative for nitrites, leukocyte esterase, protein, blood, glucose, urobilinogen, and bilirubin.

Assume that the urine diagnostic test strip is the only test that can be performed immediately in the office; any

other diagnostic studies will have to be sent to an outside laboratory.

After writing the SOAP note, answer the following questions.

1. Did you decide not to include in your documentation any of the subjective information that was given?

Why or why not?

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2. Do you feel additional subjective information should be documented that was not provided? If so, list.

3. Do you feel additional objective information should be documented that was not provided? If so, list.

4. Are you able to establish a definitive diagnosis for M. J. at this encounter? Why or why not?

5. List any assessments you included in your documentation and ICD-10 codes for any that would be billed

as part of this visit.

6. How many elements of the plan, described previously under the Plan section, are included in your

documentation?

Writing a SOAP note is sometimes difficult for students or health-care providers with limited experience,

especially formulating the plan of care. If you found it challenging, compare your SOAP note with others and

seek feedback from faculty or other experienced providers.

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Name

Abbreviations

These abbreviations were introduced in Chapter 3. Beside each, write the meaning as indicated by the context

in this chapter.

Worksheet 3.8

BMP

EMR

H&P

Hct

Hgb

ICD-10

OB/GYN

PMH

RICE

CBC

DDX

GYN

HPI

MRI

OTC

PRN

RLQ

ROS

SOAP

UTI

WBC

WNL

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Documenting Prenatal Care and Perinatal Events LEARNING OUTCOMES

• Identify components of the history, physical examination, and laboratory screening tests that are done at the first prenatal visit.

• List components of a detailed maternal history. • Identify elements of the physical examination that are performed at the initial prenatal visit. • List common laboratory and diagnostic tests done during pregnancy. • Identify common topics that should be included in patient education throughout pregnancy. • List components of a delivery note and postpartum note. • List components of a newborn physical examination. • Identify elements of the Apgar and New Ballard scores.

Introduction Good prenatal care depends on many factors but is facilitated by a good prenatal record. The prenatal record guides and documents the delivery of prenatal care. Standard prenatal record systems facilitate the transfer of information, incorporate risk assessment, and are revised and updated regularly. The use of standardized prenatal care records helps to ensure complete documentation of the care provided throughout a woman’s pregnancy. This can be beneficial in the event of medical or legal questions regarding the care provided. Several excellent standardized prenatal record systems are available. Prenatal records vary from simple notes made on blank sheets of paper to highly developed computer-based systems. Among some of the most widely used are the American College of Obstetricians and Gynecologists (ACOG) prenatal record and the Maternal/Newborn Record System. Some offices and institutions develop their own prenatal record forms to fit the special needs and interests of the providers using them. The major disadvantage of individually developed record systems is that they may not be updated regularly and may result in suboptimal care.

Ideally, women who want to become pregnant will be counseled on preconception care during regular health-care visits; however, prenatal care is often the primary way young women access basic health care. With that in mind, health-care providers should look at prenatal care in the context of risk assessment, health promotion, and risk-directed intervention in general and not just from an obstetric perspective. This means that a broad range of issues must be systematically and consistently addressed and documented during prenatal visits. Women who have prenatal care in the first trimester have better outcomes than women with little or no prenatal care. Once pregnancy is confirmed, there is a well-established timeline of prenatal care. The first prenatal visit usually takes place between weeks 8 and 12. Typically, prenatal visits for women with average risk occur monthly through week 28. Visits are every two weeks from 28 to 36 weeks, and from week 36 to delivery, patients are seen weekly. The frequency and timing of visits may change if a patient is determined to have a high-risk pregnancy. Around 38 weeks, prenatal records are sent to the facility where the patient plans to deliver. Some electronic medical record (EMR) systems have features that transfer prenatal information into the neonatal record.

PART II Documentation Related to Outpatient Care

Chapter 4

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80 | Guide to Clinical Documentation

Documentation of Prenatal Care Demographic Information Basic demographic information includes the patient’s age, marital status, relationship between the father of the baby and the patient, occupation, self-identified ethnicity, religious preference, educational background, and contact information. Demographic information can be important in evaluating risk (e.g., available support systems, living arrangements), guiding educational plans (e.g., educational level and preferred language), and identifying potential cultural or religious restrictions that may affect care during the pregnancy (e.g., unwilling to accept blood transfusions). Payer information is often documented as well. Maternal History During the initial prenatal visit, you will collect most of the information that you will use to evaluate ob- stetric risks and determine what special interventions, if any, might be needed at delivery. Risk assessment is accomplished primarily by obtaining a detailed maternal history, by performing a comprehensive physical examination, and by performing screening laboratory tests with the goal of identifying risk fac- tors to prevent an adverse outcome to the pregnancy. Specific maternal history that you should document includes menstrual history, previous obstetric history, past medical and surgical history, and infection history. For menstrual history, document whether the patient has regular or irregular menses as well as the number of days in the patient’s menstrual cycle. Document the

first day of the last menstrual period (LMP), and then calculate the preliminary estimated due date (EDD; also, estimated date of confinement, or EDC). It is important to determine the correct EDD because it will guide the remainder of the patient’s prenatal care. Obstetric history should include gravidity (sometimes referred to as gravida and documented as G) and parity (sometimes referred to as para and documented as P). Gravidity indicates the number of times a woman has been pregnant, regardless of the pregnancy outcome. Each pregnancy is counted only one time, even if the pregnancy was a multiple gestation, such as twins or triplets. A current pregnancy, if any, is included in this count. Parity reflects the total number of births after 20 weeks, regardless of the number of fetuses or outcomes. Abortus means pregnancy loss for any reason, including abortion and miscarriage. Another way to document a more complete description of pregnancy outcomes is to record the number of term deliveries, preterm deliveries (prior to 37 weeks), abortions, and live births (remembered by using the acronym TPAL). Table 4-1 describes what specific information should be elicited in each history section. The initial prenatal visit also should include maternal and paternal screening for disorders that have a genetic tendency, including thalassemia, neural tube defect, congenital heart defect, Down syndrome, Tay-Sachs, Canavan disease, cystic fibrosis, Huntington chorea, sickle cell disease or trait, mental retardation, autism, recurrent pregnancy loss or stillbirth, hemophilia, and muscular dystrophy as well as any birth defects other than those listed.

Based on your reading, complete the application exercise that follows.

Application Exercise 4.1 Calculate gravidity, parity, and abortus for the following: 1. Woman with one 8-week pregnancy loss, birth of twins at 36 weeks of pregnancy, and a live birth of a

single infant at 40 weeks. G ___ P ____ A____ 2. Woman with two pregnancies, neither of which survived to a gestational age of 24 weeks, who is

pregnant now at 30 weeks. G___ P ____ A ____ 3. Document gravidity and parity using TPAL for a woman who is pregnant now, delivered preterm twins at

33 weeks, and has a 4-year-old daughter. G___T___P___A___L___

Application Exercise 4.1 Answer 1. G3, P2, A1 2. G3, P0, A2 3. G3, T1, P1, A0, L3

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Chapter 4 Documenting Prenatal Care and Perinatal Events | 81

Physical Examination It is equally important to document the initial physical examination. Be sure to record maternal height, prepreg- nancy and current weight, and body mass index (BMI) at the initial visit. You should document maternal weight at all subsequent visits. Due to the number of women who do not seek preventive medical care, it is important to perform and document a comprehensive physical exam- ination, as discussed in Chapter 2. A pelvic examination done at the initial visit may identify cervical and pelvic abnormalities, and you should document the size of the uterus in conjunction with estimated gestational age. The pelvic examination should include cervical cytology if the patient is not up to date according to the guidelines determined by the American Society for Colposcopy and Cervical Pathology (ASCCP) and ACOG. Current guidelines may be viewed at www.asccp.org and www. acog.org. If a pelvic examination has recently been per- formed and a Pap smear is not indicated, you may consider omitting the examination and testing a urine sample for chlamydia and gonorrhea.

Documentation of fetal heart rate should take place at every visit. An ultrasound is used to detect cardiac activity prior to 12 weeks. After 12 weeks, fetal heart tones can be detected with a doppler ultrasound. If no heart rate

is detected, obtain an ultrasound to assess fetal age and viability. Document fundal height or assessment of fetal growth at each visit from 20 weeks to delivery. If maternal BMI is greater than 40, consider an ultrasound to assess fetal growth at 28 and 32 weeks. Assess fetal presentation after 34 weeks by Leopold maneuver and/or ultrasound.

The Bishop score (also known as cervix score) is a group of measurements used to rate the readiness of the cervix for labor. The Bishop score consists of five measurements of the cervix: dilation, effacement, station of the fetus, position, and consistency. Scores range from 1 to 10; if the score is more than 8, the probability of vaginal delivery after labor induction is similar to that after spontaneous labor. A Bishop score of 6 or less indicates an unfavorable cervix. Dilation is the most important element of the Bishop score. Dilation is the distance the cervix is opened, measured in centimeters (cm). Points are given from 0 to 3. Effacement (also called shortening or thinning) is reported as a percentage from 0% (normal length cervix) to 100% or complete (paper-thin cervix). Points are given from 0 to a maxi- mum of 3 points for a cervix effaced to 80% or greater. Station is the position of the baby’s head relative to the ischial spines. Negative numbers indicate that the head is above the ischial spines; positive numbers indicate that

Table 4-1 Detailed Maternal History

Menstrual History • Last menstrual period (LMP) • Age at menarche • Frequency of menses • Length of menstrual cycle Previous Obstetric History • Date(s) of delivery • Gestation in weeks • Length of labor • Birth weight • Delivery type (vaginal, cesarean) • Anesthesia type • Place of delivery • Perinatal mortality • Preterm labor • Gender of baby/babies • Complication • Gravida and para status • Any stays for neonatal intensive care Infection History • Tuberculosis exposure • Genital herpes • History of sexually transmitted infections, such as gonor-

rhea, chlamydia, human papillomavirus, syphilis, HIV • Rash or viral illness since LMP • Risk factors and immunization status for hepatitis B • Risk factors for HIV

Past Medical History • Immunization status • Diabetes • Hypertension • Heart disease • Autoimmune disorders • Kidney disease/UTIs • Psychiatric illness, including depression • Neurological/seizure disorders • Hepatitis/liver disease • Varicosities/phlebitis • Thyroid dysfunction • Pulmonary disease • Medication allergies • Gynecological surgery • Surgeries/hospitalizations • Anesthesia complications • Abnormal Pap smears • Uterine anomaly • Exposure to diethylstilbestrol (DES) in utero • Infertility • Blood transfusions • Trauma/intimate partner violence • Use of tobacco, alcohol, illegal drugs by amount,

frequency, and length of use • Complete medication history, including all prescribed

and over-the-counter medications, herbal and dietary supplements, and vitamins

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Down syndrome and 97% with trisomy 18. The FTS measures blood levels of free beta-human chorionic gonadotropin (hCG) and pregnancy associated plasma protein A (PAPP-A) at around 9 to 14 weeks. In addition, an ultrasound is performed around 11 to 14 weeks to assess the nuchal translucency. Women should be offered maternal serum alpha-fetoprotein (ms-AFP) screening between 15 and 22 weeks to assess for neural tube defects.

Although not typically completed at the first prenatal visit, the quadruple screen test can identify about 80% of fetuses with Down syndrome, 80% of those with open neural tube defects, and 60% with trisomy 18. This test measures blood levels of alpha-fetoprotein, beta-hCG, estriol, and inhibin A. It is performed between the 15th and 22nd weeks.

A pelvic and transvaginal ultrasound is performed to determine that the pregnancy is viable and to confirm the EDD. Additional ultrasounds may be performed between 18 and 20 weeks to assess fetal anatomy and then around 30 weeks to evaluate fetal growth.

In addition to documentation of all test results, be sure to document a treatment plan to address any abnormal results. It is beyond the scope of this book to address medical treatment, but information on medical management and clinical practice guidelines is readily available (see the Bibliography).

the head is below the ischial spines. Points are given from 0 to a maximum of 3 points for a station of 1+ or 2+. Position refers to the positioning of the cervix. If the cervix faces front (anterior), it is more favorable, whereas posterior is less favorable. Consistency of the cervix is measured on a scale of firmness from firm to soft. The softer the cervix, the better the chance of vaginal delivery. Table 4-2 shows the components of the Bishop score.

Laboratory Data and Diagnostic Tests There are many routine laboratory screening tests that you should order at the first prenatal visit and then again at 28 weeks. At the first visit, order a confirmatory preg- nancy test, even if the patient reports a positive home pregnancy test. Obtain a complete blood count (CBC) to evaluate hemoglobin and hematocrit levels to screen for anemia as well as to establish baseline platelet count. Be sure ABO and Rh(D) blood typing and antibody status are done. Chemistry tests may include thyroid stimulating hormone (TSH) and fasting blood glucose (FBG). Immunologic markers screen for rubella, HIV, hepatitis B surface antigen, and hepatitis C. Syphilis screening is done by ordering rapid plasma reagin (RPR). Ensure that urinalysis and urine culture are done. You should obtain vaginal cultures to test for gonorrhea and chlamydia. Testing for trichomoniasis may be included if the patient is considered high risk for sexually transmitted infections (STIs). If the patient is symptomatic, you may consider testing for bacterial vaginosis and candidiasis.

Genetic screening may be done for conditions such as cystic fibrosis and hemoglobinopathies if indicated by maternal or paternal history. You should offer aneuploidy screening options to all pregnant women presenting for care, regardless of age. In addition, you can offer consul- tation with a genetic counselor to all women considered high risk due to maternal age (age 35 or over at delivery). Any patient with a personal or family history of genetic disease should be referred to a perinatologist for further evaluation once a viable pregnancy is confirmed. Prior to performing a screening test, you should have a discussion with the patient about possible results and subsequent evaluation. There are many noninvasive screening options available. One example is the First Trimester Screen (FTS), a panel of screening tests that can identify about 85% of pregnancies in which the fetus shows signs indicative of

MEDICOLEGAL ALERT !

The number of laboratory tests done during pregnancy is staggering. Review of closed malpractice claims and patient safety assessments reveal that inadequate tracking of clinical laboratory and diagnostic tests is a top factor leading to patient injury, affecting not only the mother but also potentially the developing fetus. All providers and institutions must have a system to manage test results that includes tracking tests until the results have been received, notifying patients of the results, documenting that the notification occurred, and making sure that patients with abnormal results receive the recommended follow-up care. One of the strongest arguments in favor of an EMR system is that it manages test results efficiently and reliably. Regardless of the type of system used, failure to manage test results correctly and/or failure to document any step of the process is failure to meet the standard of care.

Score Dilation Effacement Station Position Consistency 0 Closed 0–30% -3 Posterior Firm 1 1–2 cm 40–50% -2 Midposition Medium 2 3–4 cm 60–70% -1, 0 Anterior Soft 3 5+ cm 80+% +1, +2

Table 4-2 Bishop Score Components

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Chapter 4 Documenting Prenatal Care and Perinatal Events | 83

least once during pregnancy and again after delivery, every patient should be screened for risk of developing postpartum depression using a standardized, validated tool such as the Edinburg Postnatal Depression Scale (EPDS). The EPDS consists of ten self-reported items and takes less than five minutes to complete. Interventions, such as education on coping techniques, medication, or referral to a mental health provider, should be provided and documented as needed. If a patient admits to thoughts of or has a plan for suicide, she should be referred immediately to the appropriate crisis response team or resource.

Patient Education Patient education is cited as an important part of achieving a good pregnancy outcome. It is wise to document educational interventions as further evi- dence of the provision of high-quality prenatal care. It probably is not necessary to document detailed educational material; it is sufficient to note the topics covered. Other educational topics include exercise, seat belt use, activities to avoid, anticipated discomforts during pregnancy, and symptoms that should prompt urgent evaluation. Some professional organizations offer educational materials that can be customized for specific practices and are available in multiple formats and different languages.

During the remainder of the pregnancy, prenatal care occurs at regular intervals as stated previously. Table 4-3 shows the history and physical examination, testing and treatment, and educational topics included in the interval visits.

Documentation of Perinatal and Postpartum Care Delivery Note Labor and delivery typically takes place at a hospital and the means of documenting obstetric care are dictated by the institution’s record-keeping system, therefore detailed discussion of that documentation is not pre- sented in this text. Information about commercially available perinatal records and software systems is readily available.

A delivery note is used to document the outcome of an obstetric admission (Fig. 4-1). In many hospitals, the physician in attendance at the time of delivery is respon- sible for dictating a complete delivery record. A delivery note serves to document some details of the delivery until the final transcribed report is placed in the patient’s chart. Typically, the delivery note is part of the maternal record; however, some EMR systems integrate the delivery note into both the maternal and neonatal record.

Health Promotion and Disease Prevention You will provide the majority of counseling related to health promotion and disease prevention at the first pre- natal visit. You may address some topics, such as weight gain, teratogen avoidance, and medication use, at every prenatal visit. Be sure to document immunization status, specifically for influenza and tetanus-diphtheria-pertussis (Tdap) vaccines. Complete guidelines for recommended vaccinations for pregnant women are available at www. cdc.gov/vaccines/pregnancy and www.acog.org.

Nutrition The initial nutritional status and the ongoing quality of maternal nutrition during pregnancy are widely believed to affect the outcome of pregnancy. Women with certain medical problems, such as diabetes or phenylketonuria, have specific nutritional needs and may need referral for nutrition assessment and recommendations. Educating patients on optimal weight gain during pregnancy can help prevent complications during pregnancy and labor. Excessive weight gain or failure to gain weight during the pregnancy may prompt further nutritional evaluation. Specific nutritional education should include folic acid and calcium supplementation as well as use of a prenatal vitamin. Education should be provided on what foods should be avoided or limited to prevent food-borne illnesses or toxicities.

Psychosocial Factors At the initial prenatal visit, you will perform screening for use of tobacco, alcohol, and illicit drugs (also part of the adult preventive care visit, discussed in Chapter 6). Tobacco use during pregnancy has well-known risks, including miscarriage, placental abruption, fetal growth restriction, preterm delivery, birth defects such as cleft lip and palate, and sudden infant death syndrome. Cessation of tobacco use is highly recommended. Document that the mother was educated on the risk of smoking, advised on smoking cessation, and, if applicable, given intervention materials to aid with cessation. Alcohol is a known teratogen, and use of alcohol during pregnancy incurs a risk for fetal alcohol syndrome. Similarly, use of narcotics and other con- trolled or illicit substances can adversely affect fetal well-being. Two screening tools for alcohol screening, CAGE and T-ACE, and several screening tools related to drug use, are discussed in Chapter 6. The incidence of intimate partner violence (IPV) is known to increase during pregnancy. Screening for IPV is recommended at the preconception visit, the initial prenatal visit, at 28 weeks, and in the postpartum period. The rate of detection can be higher when there is screening at multiple visits rather than only the initial visit. At

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Gestational Age History and Physical Examination Testing and Treatment Education and Planning

Preconception to 12 weeks

Detailed maternal history; comprehensive physical examination; height, weight, BMI, blood pressure, pelvic examination

Blood type and antibody screen; hemoglobin and hematocrit; platelet count; hepatitis B surface antigen; HIV; screening for gonorrhea, chlamydia, syphilis; urine culture; varicella titer, hepatitis C, tuberculosis testing; influenza vaccination

Counsel of significant positive findings elicited by history, physical or test results; screening for aneuploidy; nutrition in pregnancy; weight gain in pregnancy; obesity counseling if applicable; teratogen avoidance; refer for genetic counseling if indicated; refer to high risk if indicated

12–16 weeks Interim medical and nutritional history; fetal movement; weight and blood pressure; fetal heart rate

First trimester screen (FTS); diabetes screening at 12 weeks; influenza vaccination if not done previously; urine dip for protein and glucose

Safe sex during pregnancy; exercise and fitness during pregnancy; managing work during pregnancy; seat belt use during pregnancy; teratogen avoidance

16–22 weeks Interim medical and nutritional history; fetal movement; weight and blood pressure; fetal heart rate; fundal height and growth

Quad screen; ultrasound; urine dip for protein and glucose; progesterone for prevention of recurrent preterm birth if indicated

Self-help for common discomforts; teratogen avoidance; fetal growth and development; general health habits; childbirth classes; emotional changes during pregnancy; trauma protocol in pregnancy

22–28 weeks Interim medical and nutritional history; fetal movement; weight and blood pressure; fetal heart rate; fundal height and growth; fetal lie and presentation

Hemoglobin and hematocrit; platelet count; urine dip for protein and glucose; diabetes screening; antibody screening in Rh(-) women

Signs of complications including preterm labor and pre-eclampsia; parenting and infant classes; breastfeeding classes; contraception and family planning; work plans; VBAC/TOLAC if indicated

28–34 weeks Interim medical and nutritional history; fetal movement; weight and blood pressure; fetal heart rate; fundal height and growth; fetal lie and presentation; screen for IPV; screen for depression

Tdap vaccination; RhoD immune globulin at 28–29 weeks in Rh(-) women; urine dip for protein and glucose; nonstress testing after 32 weeks

Self-help for common discomforts; teratogen avoidance; fetal growth and development; general health habits; fetal movement; anticipatory guidance regarding labor and delivery; infant car seat safety information; birth plan (when to call and where to go); physical and emotional changes

34–38 weeks Interim medical and nutritional history; fetal movement; weight and blood pressure; fetal heart rate; fundal height and growth; fetal lie and presentation; fetal engagement; screen for IPV; screen for depression

Repeat STI and HIV screening; vaginal and rectal cultures for Group B strep; urine dip for protein and glucose; nonstress testing

Self-help for common discomforts; teratogen avoidance; fetal growth and development; general health habits; fetal movement; anticipatory guidance regarding labor and delivery; infant car seat safety information; infant safety after birth; caring for self and infant after delivery

38 weeks to delivery

Interim medical and nutritional history; fetal movement; weight and blood pressure; cervical examination; fetal heart rate; fundal height and growth; fetal lie and presentation; fetal engagement; screen for IPV; screen for depression

Nonstress testing if indicated; urine dip for protein and glucose

Signs of labor; birth plan (when to call and where to go)

Table 4-3 Visits Throughout Pregnancy

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Figure 4-1 Sample delivery note in an EMR.

Procedure: vaginal delivery

Name: CM Age: 18 years Gravidity and Parity upon Admission: Formula: G 1, P 0 0 0 0. Gravidity - 1, Parity - 0, Term - 0, Preterm - 0, Abortions - 0, Living Children - 0, Multiple Deliveries - 0, CS - 0. Gestational Age at Delivery: 39 weeks + 3 days. Maternal Information: Maternal ABO type: A positive. Hepatitis B Surface Antigen: negative. Negative Group B Streptococcus. Rapid Plasma Reagin: nonreactive. Rubella Screen (IgG): positive. Human Immunodeficiency Virus 1 Antibody Screen (ELISA): nonreactive. Drugs Administered: Lidocaine-Epinephrine, Lactated Ringer’s. Medical History: Anemia since 03/15/2017. No history of Guillain-Barré syndrome. Drug allergies: exist. Pregnancy complications: Anemia: exists since 03/15/2017.

Delivery Room Number: 2

Contractions Beginning Date: 07/29/2017 Contractions Beginning Time: 01:15 First Stage: 7 hours + 27 minutes Second Stage: 0 hours + 36 minutes

Neonate (Type of Delivery: Normal Vaginal Delivery)

Membranes: Spontaneous Rupture of Membranes (04:02 07/29/2017) Maternal delivery position: lithotomy Interventions: internal fetal heart rate monitor, internal tocometer. Time of Delivery: Sex: male ID Band Number: C14205 09:18 07/29/2017 Weight 3,125 gm (6 lb+ 14.231 oz) Length 48 cm (18.9 inches) Baby Medical Record No. 420319 Head Circumference: 35 cm (13.8 inches) Chest Circumference: 31 cm (12.2 inches) Pediatrician: Broom. Live Born: yes Fetal Presentation: cephalic Fetal Position: OA Last documented amniotic fluid color (04:02 07/29/2017): clear. ROM at delivery details: Amniotic Fluid Color: clear

No evident neonatal anomaly.

Apgar 1 min: 9 Apgar specification: Color: Acrocyanotic (1); Heart Rate: Above 100 (2); Irritability: Cry/Active withdrawal (2); Tone: Active Motion (2); Respiration: Good, Crying (2). Apgar 5 min: 9 Apgar specification: Color: Acrocyanotic (1); Heart Rate: Above 100 (2); Irritability: Cry/Active withdrawal (2); Tone: Active Motion (2); Respiration: Good, Crying (2). Apgar assigned by: Kendra Marshall, RN Cord blood was sent. Interventions/Resuscitation: Newborn Care: spontaneous cry, infant on mom’s abdomen directly, mom and infant bonding, infant disposition—with mother, cardiopulmonary resuscitation was not done, nursery called at 09:13 07/29/2017, nursery present at 09:14 07/29/2017. Neonatal Airway Suction: no respiratory assistance was given. Oxygen: oxygen was not administered. Placenta: The placenta was delivered with assistance. Placenta was intact. On cord examination: 3 vessel cord. Section of cord retained (section length: 10 cm). There were cord abnormalities: cord wrapped around neck 1 wrap tightly (clamped and cut).

Delivery Procedures

Labor augmentation was done. Mode of augmentation: Oxytocin. Anesthesia: epidural.

Block performed by Menal Urcis, MD. No fundal pressure applied. No double setup.

Straight catheterization (AT 0850 BEFORE DELIVERY) was done.

Lacerations and repairs. There were second degree perineal lacerations, which were repaired by Charlene Colwell, DO, using Vicryl sutures. There were vaginal lacerations, which were located bilaterally and which were repaired by Charlene Colwell, DO, using Vicryl sutures. Complications The esteemed blood loss during the delivery was 400 mL.

Cervix, fundus, and vault inspected and intact. Attending Notes: Attended Normal Vaginal Delivery. Patient tolerated well. No complications. See delivery note for detail. Agree with care as ordered. Charlene Colwell, DO.

Delivery Report

Vaginal Delivery

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Postpartum Note Often you will use the SOAP (Subjective, Objective, Assessment, Plan) note format, discussed in Chapter 3, for documenting postpartum visits. Subjective informa- tion that you should document includes any complaints the patient may have, ability to ambulate, pain control, whether patient is breastfeeding or bottle feeding, and ability to void. If postoperative, ask the patient about presence or absence of flatus. Objective findings that you should document include general assessment, vital signs, breast examination, uterine tone, fundal height, and amount and character of lochia. If postoperative, document the appearance of the surgical incision; if the patient had an episiotomy, document the appearance of the perineum. Be sure to include important labo- ratory data such as hemoglobin, even if normal, and any abnormal values from the CBC. Your assessment should include any problems that you identified. Your plan should include any patient education provided, birth control plans, and when a routine postpartum office visit should be scheduled. Review the postpartum note shown in Example 4.2.

EXAMPLE 4.2

Postpartum Day (PPD) # 1

S: Patient c/o mild cramping, tolerating regular diet, ambulating without difficulty. Able to void without difficulty, no bowel movement (BM) today. Denies nausea, vomiting (N/V), shor tness of breath (SOB), fever, breast tenderness. She is breastfeeding the infant and is having some difficulty getting the child to latch. She would like to go home with oral contraception.

O: General: 27-year-old G2, P2 lying comfor tably in bed and holding infant

VS: T 97.8, T max: 98.9 P: 100 RR: 14 BP: 120/80 Resp: Clear to auscultation all fields without

wheezing

The key information that you should document in a delivery note includes the following: • Age, gravidity (G), and parity (P) of mother • Labor progression (spontaneous or augmented) • Duration of labor • Type of delivery (vaginal, cesarean) • Viability of the fetus • Sex of the fetus • Presentation of fetus • Apgar scores at 1 and 5 minutes (see Table 4-4

for criteria for Apgar score) • Weight of the fetus • Delivery of the placenta, including number of

vessels in the umbilical cord and whether the pla- centa was intact

• Uterine tone • For any lacerations or episiotomies, what extent

and how repaired • Estimated blood loss (EBL) • Condition of mother immediately after delivery

Review the delivery note shown in Example 4.1.

EXAMPLE 4.1

Delivery Note: Include Date and Time

This is a 27-year-old G2 now P2 who was admitted for active labor. She progressed with Pitocin augmentation to second stage of labor. She pushed for 4 hours, 40 minutes. She delivered a viable male infant, ROA (right occiput anterior), over a first-degree midline episiotomy. The mouth and nares were suctioned on the perineum. No nuchal cord. Apgar scores were 7 and 9. Infant weight 7 pounds 2 oz. Intact placenta expelled spontaneously, three-vessel cord. No vaginal or cervical lacerations. Episiotomy repaired with 2-0 chromic. The uterus was firm with no active bleeding. The repair was done under epidural anesthesia. EBL was 500 mL. No immediate complications. Mom and baby bonding following deliver y.

Table 4-4 Apgar Scoring Criteria*

Clinical Sign Criteria for Assigned Points 0 Points 1 Point 2 Points

Heart rate Absent Less than 100 Greater than 100 Respiratory effort Absent Slow and irregular Good; strong Muscle tone Flaccid Some flexion of the arms

and legs Active movements

Reflex irritability (reaction to suction of nares with bulb syringe)

No response Grimace Vigorous cry, sneeze, or cough

Color Blue, pale Pink body, blue extremities Pink all over

*Score of 0 to 4 at 1 minute after birth indicates severe depression, requiring immediate resuscitation; score of 5 to 7 indicates some nervous system depression, and score of 8 to 10 is normal. Score of 0 to 7 at 5 minutes after birth indicates high risk for subsequent dysfunction of the central nervous system and other organ systems; score of 8 to 10 is normal.

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Chapter 4 Documenting Prenatal Care and Perinatal Events | 87

CV: Regular rate, +S1+S2, no murmur, rubs, or gallop Breasts: + engorged, no er ythema Abd: Soft, nontender. Fundus is one fingerbreadth

below the umbilicus, firm Perineum: Moderate lochia, no clots or foul odor ;

episiotomy intact, no hematoma or signs of infection

Ext: No lower extremity tenderness or edema Labs: Mother A+, infant AB+, RPR neg, rubella

immune CBC: WBC = 13.2, Hgb 9.8 A: 27-year-old G2, P2 PPD #1 SVD (spontaneous

vaginal deliver y); no acute problems P: 1. Lactation nurse to assist 2. Desires oral contraception, RX Micronor to

star t at 3 weeks 3. Continue prenatal vitamins 4. Motrin and Norco 5/325 for pain; Colace BID

Newborn Physical Examination The purpose of the newborn physical examination is to assess the baby’s transition from intrauterine life to extra- uterine existence and to detect congenital malformations and actual or potential disease. Examine the baby briefly immediately after birth, screening for anomalies or disease that might mandate emergency treatment. Perform the Apgar assessment to calculate the score at 1 and 5 min- utes of life. Perform a complete examination within the first 24 hours that includes a head-to-toe examination and assessment of gestational age, frequently through a scoring system that combines physical characteristics with neuromuscular development, such as the New Ballard score. Detailed information about the New Ballard score is available at www.ballardscore.com; score sheets for documenting the assessment are also available through the website. A sample newborn history and physical examination (H&P) is shown in Figure 4-2.

Summary Young women may not access basic preventive care unless they become pregnant; therefore, you should look at prenatal care in the context of risk assessment, health promotion, and risk-directed intervention in general and not just from an obstetric perspective. A number of formats are available to document prenatal care, including preprinted forms from national specialty organizations or commercial vendors and electronic systems. Prenatal records not only document the care that is provided, but may direct care as well. During the initial prenatal visit, collect most of the informa- tion that will be used to evaluate obstetric risks and determine what special interventions, if any, might be needed at delivery. Well-established guidelines exist that can guide you in obtaining and documenting a detailed maternal history, performing physical exam- inations throughout the pregnancy, tracking labora- tory studies, and educating the patient about health promotion and disease prevention during pregnancy. A delivery note documents the outcome of an ob- stetric admission. Postpartum notes detail maternal status after delivery. Some elements of the prenatal and delivery records may be incorporated into the neonatal record. Documentation of a newborn history and physical examination is critical to establish the baby’s transition from intrauterine life to extrauterine existence. Care of the infant then transitions from the obstetric to a pediatric health-care provider; documen- tation of pediatric and adolescent visits is discussed in Chapter 5. Completing the worksheets that follow will help reinforce the content of this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation. You can follow documentation through the mother’s pregnancy and birth of the baby.

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Figure 4-2 Newborn history and physical examination.

Newborn History and Physical Examination

HISTORY:

HPI: Baby Boy Nguyen was born at 39+6 weeks by NSVD. Delivery was uneventful and gestational age by LMP consistent with 22-week ultrasound. Apgar scores of 7 and 9. Baby has been doing well since birth, breastfed x3, stool x1, and void x1. Mom states that feedings are going well.

MATERNAL HISTORY: 27 yo G2P1001 mom with prenatal labs O+, Ab screen negative, HBsAg negative, VDRL nonreactive, GC/CT negative, HIV negative, Group B strep negative. Mom took folic acid prior to conception. Prenatal care initiated in first trimester with 13 documented prenatal visits. Mom did not smoke, drink alcohol, or use illicit drugs during pregnancy. Pregnancy was uncomplicated. ROM was 7 hours prior to delivery with clear fluid.

Maternal medications: Mom took prenatal vitamins daily. Only other medication was amoxicillin at 23 weeks when mom had UTI; and OTC antacids PRN starting at 34 weeks.

Maternal allergies: NKDA

FH: sibling under bili lights for 2 days in newborn nursery, negative for congenital diseases, childhood deaths, or atopic diseases.

SH: intact family, 3 yo sib. Mom has all baby needs including car seat. Plans to use Pinnacle Pediatrics.

PHYSICAL EXAMINATION: Weight: 7 lb 2 oz / 3265 g Length: 19.8 in / 50.3 cm OFC: 13.5 in / 34.4 cm

Temp: 36.7 HR: 145 RR 52

General: well appearing, alert, active, nondysmorphic appearing infant in no distress

Skin: warm, no cyanosis, no jaundice, + red macules with central papules scattered on chest and legs

HEENT: normocephalic, anterior fontanelle open and flat. Red reflex present both eyes; ears normal set/shape; nares patent, palate intact, mucous membranes moist, tongue midline

Neck: full ROM, clavicles intact bilaterally

Lungs: clear to auscultation bilaterally, no retractions

CV: RRR without murmur, femoral pulses +2 bilaterally Abd: soft, nondistended, liver palpable 2 cm below right costal margin. Normal bowel sounds. Umbilical stump intact/clamped

Genitalia: normal male with testes descended bilaterally, anus patent

Musculoskeletal: negative Barlow and Ortolani. Spine straight. No sacral dimples or hair tuft. Leg lengths symmetric. Five fingers on each hand and 5 toes on each foot; no deformity.

Neurological: normal tone; normal suck, grasp, root and Moro reflexes, DTRs +2 bilaterally. Ballard score = 18 neuromuscular, 17 physical = 35 total

DIAGNOSTIC STUDIES: Dextrose stick: 87

ASSESSMENT/PLAN: 1. Term AGA newborn; routine newborn care. 2. Erythema toxicum rash: expect spontaneous resolution of rash within 1–2 weeks 3. Anticipatory guidance 4. Hepatitis B immunization prior to discharge

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Worksheet 4.1

Name

Review

1. List five components of maternal history that should be elicited during the first prenatal visit.

2. List four components of physical examination that should be done at every prenatal visit from 16 weeks

throughout the remainder of the pregnancy.

3. List five laboratory screening tests that should be completed during the initial prenatal visit.

4. List at least four disorders that have a genetic tendency that should be screened for in both maternal and

paternal history.

5. List at least five topics that should be addressed as part of health promotion and disease prevention coun-

seling throughout pregnancy.

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6. List the elements of a delivery note.

7. Identify subjective information that should be documented in a postpartum note.

8. Identify objective information that should be documented in a postpartum note.

9. Discuss the purpose of and components of the New Ballard score.

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Worksheet 4.2

Name

Abbreviations

These abbreviations were introduced in Chapter 4. Beside each, write the meaning as indicated by the content

of this chapter.

ACOG

BID

BMI

EBL

EDD

EPDS

FTS

H&P

IPV

ms-AFP

PAPP-A

ROA

SOAP

STIs

Tdap

ASCCP

CBC

EDC

EMR

FBG

G, P

hCG

LMP

N/V

PPD

RPR

SOB

SVD

TSH

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Pediatric Preventive Care Visits LEARNING OUTCOMES

• Discuss the goals of the Medicaid Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program and the American Academy of Pediatrics’ Bright Futures program.

• Identify measurements that are used as part of growth screening. • Discuss developmental milestones and screening tools used to evaluate attainment of these milestones. • Identify laboratory tests that are part of newborn screening and preventive care visits. • Identify resources for pediatric vaccination schedules and discuss information that must be

documented when vaccines are administered. • Discuss the importance of providing and documenting anticipatory guidance for pediatric and

adolescent patients. • Discuss risk factor identification in the pediatric and adolescent populations. • Discuss the importance of obtaining an adolescent psychosocial history and tools that may be used to

gather and document it. • Identify components of a sports preparticipation history and physical examination.

Introduction Pediatric preventive care visits, or well-child visits, are often enjoyable for the provider and may provide an opportunity for you to interact with a patient who is not “ill.” When obtaining subjective information, you will often have to rely on parents or caregivers of the patient to provide the medical history. Children at certain ages are unable to voice their problems or concerns, and you may have to rely more heavily on the objective data you obtain during a visit. Careful observation of the child’s overall status and observing interactions between the child and parent or caregiver are important parts of the pediatric preventive care visit.

Age is an important consideration when conducting and documenting well-child visits. Age is documented in months when the child is 24 months or younger and in years and months for children older than 24 months (e.g., “17 months,” and “3 years, 8 months”). Generally, patients younger than 18 years of age are considered to be pediatric patients, although some pediatric guidelines include patients up to 21 years of age. Most screening

and immunization guidelines are age specific; therefore, it is important to document the date of birth accurately and document the child’s age at each visit.

Standardized forms can be used to facilitate doc- umentation of preventive care visits for pediatric and adolescent children. Many providers use forms that have been specifically developed for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program. This federally mandated program is the child health component of Medicaid and is the most comprehen- sive child health program in either the public or private sector. EPSDT requires states to assess a child’s health needs through initial and periodic examinations and evaluations to ensure that health problems are diagnosed and treated early before they become more complex and their treatment becomes more costly. States must perform medical, vision, hearing, and dental checkups according to standardized schedules. Forms for these examinations are readily available on the Internet by using the state name and EPSDT as the search term. In addition to the EPSDT program, the Bright Futures program is a national initiative focused on the goals of disease preven- tion, risk and disease detection, and health promotion.

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The initiative is led by the American Academy of Pediatrics (AAP) and supported by the Maternal and Child Health Bureau (MCHB) and Health Resources and Services Administration (HRSA). The Bright Futures guidelines provide theory-based and evidence-driven guidance for all preventive care screenings and well-child visits. Parents complete a previsit questionnaire that addresses parental concerns, asks risk assessment questions, and gathers developmental surveillance information. Parents are encouraged to arrive early before a scheduled visit to complete the questionnaire, or if a patient portal is offered, to print and complete the questionnaire before the visit. To meet the well-child visit priorities of the patient and family, documentation forms guide health-care providers on which questions to ask and issues to address based on the child’s age and stage of development. The forms help document the visit as required by private and public payers and apply proper coding to ensure payment for each visit’s activities. Forms include sections for the his- tory, developmental surveillance, physical examination, screening, immunizations, and anticipatory guidance. Parent/patient handouts provide an opportunity to build on the topics discussed during the visit. They summarize anticipatory guidance for the visit and reinforce the Bright Futures priorities. Handouts have been developed for each visit from ages 1 week to 21 years. The fourth edition of the Bright Futures Guidelines for Health Supervi- sion of Infants, Children and Adolescents is available in summary form at www.aap.org/en-us/documents/ periodicity_schedule.pdf. The AAP has developed a set of Pediatric Visit Documentation Forms for well-child visits from the initial visit at 2 weeks of age up to the visits for patients who are 15 to 21 years old. The forms may be viewed and ordered from the organization’s website at www.aap.org. Health history forms such as the one shown in Figure 5-1 may also be used and can be tailored to a specific practice setting.

Components of Pediatric Preventive Care Visits The components of well-child visits generally follow the format of the comprehensive history and physical examination (see Table 2-1) with minor variations related to age. EPSDT-mandated components of pediatric pre- ventive care (or screening) visits include the following: • Growth screening • Developmental screening • Laboratory screening tests • Assessment of immunization status and adminis-

tration as appropriate • Anticipatory guidance, counseling, and education • Risk factor identification

Growth Screening Growth and development are important parameters that should be assessed routinely during well-child visits. Growth generally refers to the increase in size of the body as a whole or its separate parts. Growth charts are used to assess and compare a child’s growth with a nationally representative reference population and are available for boys, birth to 24 months; girls, birth to 24 months; boys, 2 to 19 years; and girls, 2 to 19 years. Growth charts provide an overview of the normal growth trajectory of children, thus alerting the provider to what is atypical or disturbed. The World Health Organization (WHO) released a new international growth standard statistical distribution in 2006, which describes the growth of children ages 0 to 59 months living in environments believed to support what WHO researchers view as optimal growth of children in six countries throughout the world, including the United States. The Centers for Disease Control and Preven- tion (CDC) recommends that health-care providers use the WHO growth charts for infants and children ages birth to 2 years and then use the CDC growth charts for children age 2 years and older. The growth charts are available from the CDC and can be viewed at and downloaded from the organization’s website at www.cdc.gov/growthcharts. The measurements typically recorded during the first 2 years of life are length (or height), weight, and head circumference. After the age of 2 years, head circumference may not be measured at every visit if the child’s development has been consistent. Body mass index (BMI) should be calculated and doc- umented beginning at 2 years of age, when an accurate stature can be obtained, to screen for childhood obesity.

A sample growth chart for plotting length and weight for age is shown in Figure 5-2. To plot the length, find the age across the top of the graph and then find the length in inches or centimeters along the left axis. Follow each line to the intersecting point and mark. To plot the weight, find the child’s age across the bottom of the graph and the weight in pounds or kilograms along the right axis. Follow each line to the intersecting point and mark. You will notice lines curving across the chart with small numbers corresponding to each line at the right side of the chart. These numbers refer to percentiles. Percentile is the most commonly used clinical indicator to assess the size and growth patterns of individual children in the United States. Percentiles rank the position of an individual by indicating what percentage of the reference population the individual would equal or exceed. For example, on the weight- for-age growth charts, a 5-year-old girl whose weight is at the 25th percentile weighs the same or more than 25% of the reference population of 5-year-old girls and weighs less than 75% of 5-year-old girls. Based on your reading, complete the application exercise that follows.

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Figure 5-1 Pediatric medical history form.

To be completed by parent or guardian Today’s Date: __/__/__

Child’s Name: ________________________________________________________ Date of Birth: __/__/__ Male Female Mother’s Name: _______________________________________ Father’s Name: _____________________________________ Address: _______________________________________________________________________________________________ Home Phone: ____________________ Mother’s Work Phone: _________________ Father’s Work Phone: _________________ Siblings’ names and ages: _________________________________________________________________________________ Person completing form/relationship: _________________________________________________________________________

Birth and Development History: Mother’s age at time of delivery: ____ Type of delivery: vaginal cesarean Birth weight: _________ Problems during pregnancy: _________________________________ Obstetrician: ______________________________________ Feeding: breast bottle Type of formula: _______________________ Vitamins: yes no

Current Medications (please include prescription and over-the-counter medications):

Name of Medication Dose (mg) Taken how many times a day?

Medical History: (Check if the child has ever had any of the following)

Allergies Anemia Asthma Bedwetting

Serious injury (type ________)

Bladder infection Breathing problems Bowel problems Easy bruising/ bleeding

Eye problems Hearing problems Kidney problems Liver problems

Feeding problems Skin problems Sleep problems Seizures

Medication allergies: None _______________________________________________________________________________

Please list any hospitalizations (other than delivery) or surgeries.

Year Procedure or Reason for Hospitalization Doctor Which hospital?

Social History: Parents’ marital status: married single separated divorced Any smokers in the house? yes no If divorced or separated, who has legal custody? __________________________________________________________________ Car Seat/Seat Belt use: yes no Helmet or other safety measures: yes no Smoke detector in the house? yes no Do you have a pool? yes no If yes, is it fenced? yes no

Immunizations (list dates and any severe reactions): DTP/Td ____________________ Oral polio ____________________ MMR ______________________ HIB-c _______________________ varicella __________________ Cocci (skin test) ______________ TB skin test __________________

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Application Exercise 5.1 On the sample growth chart shown in Figure 5.2, plot the length and weight for Kaden, a 21-month-old boy. His length is 33 inches, and his weight is 29 pounds. Determine Kaden’s percentile for length and weight.

Application Exercise 5.1 Answer Kaden’s weight is in the 75th percentile, and his length is in the 50th percentile. Compare your marks on the graph with those shown.

(continued)

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Figure 5-2 A sample growth chart. (Published by the Centers for Disease Control and Prevention. November 1, 2009. Source: WHO Child Growth Standards [http://who.int/ childgrowth/en])

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Excess weight and obesity in children are significant public health problems in the United States. A study published in the Journal of the American Medical Associ- ation ( JAMA) in 2010 reported that one of every three children in the United States is overweight or obese. The CDC recognizes four categories of weight status: underweight (less than 5th percentile), healthy weight (5th percentile to less than 85th percentile), overweight (85th to 95th percentile), and obese (equal to or greater

than 95th percentile). The National Health and Nutrition Examination Survey (2012), or NHANES, reported the obesity rates for school-aged children (6 to 11 years of age) at 17.5% and adolescents (12 to 19 years of age) at 20.5%. Being overweight or obese during childhood and adolescence increases the risk for developing high cholesterol, hypertension, respiratory ailments, ortho- pedic problems, depression, and type 2 diabetes. The incidence of type 2 diabetes has increased dramatically

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milestones are identifiable skills that can serve as a guide to normal development. Typically, simple skills need to be reached before the more complex skills are learned. There is a general age and time when most children pass through these periods of development. There are also specific speech and language milestones. Children vary in their development of speech and language; however, there is a natural progression or “timetable” for mastery of speech and language skills.

Developmental screening includes subjective in- formation from parents and caregivers and objective information observed by the clinician. If a child fails to meet developmental milestones at the appropriate age, or if there is any suspicion of developmental delay, then usually formal developmental testing is warranted.

in children and adolescents, particularly in American Indian, African American, and Hispanic/Latino popula- tions. The CDC, together with the National Center for Health Statistics, developed a graph for plotting BMI percentiles. It is shown in Figure 5-3 and is available at www.cdc.gov/growthcharts. BMI calculators are readily available online at various Internet sites.

Developmental Screening Developmental milestones are physical or behavioral signs of development or maturation of infants and children. Rolling over, crawling, walking, and talking are considered developmental milestones and provide essential information regarding the child’s development. The milestones are different for each age range. The

Figure 5-3 Body mass index graph. (Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion [2000] and modified 10/16/00.)

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(ASQ-3). It contains 21 age-specific questionnaires, which allow for accurate screening anytime between 1 month and 5½ years of age. Questions ask parents to answer “yes,” “sometimes,” or “not yet.” It takes approx- imately 10 to 15 minutes for parents to complete and 2 to 3 minutes for scoring. There is an initial cost for the kit, which provides a user guide, scoring sheets, and a master set of all 21 questionnaires for printing and photocopying. The third edition is available in English and Spanish; the second edition is available in French. More information is available at http://agesandstages .com/products-services/asq3.

Laboratory Screening Tests The goal of screening is to decrease or to eliminate the catastrophic effects of preventable mental retardation. Genetic disease gained recognition with the introduction of the newborn screening program for phenylketonuria (PKU). In the United States, the early screening of children for special health-care needs and congenital disorders begins in the newborn period. Under the direction of state public health agencies, all infants are tested for certain genetic conditions, such as hemo- globinopathies, metabolic disorders, hearing loss, and other congenital conditions.

Although newborn screening programs differ state by state, there are national recommendations to guide and support states in the development of their program. The committee that works to set these national guidelines is called the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children. In addition, the secretary of the U.S. Department of Health and Human Services reviews the committee’s recommendations. They work together to create the Recommended Uniform Screening Panel (RUSP). The RUSP is a list of 34 core conditions and 26 secondary conditions which every baby should be screened for. The RUSP recommendation is not a law, but it serves as a helpful guide for the states. A list of conditions screened for by state may be viewed at http://babysfirsttest.org/newborn-screening/states. Many of these tests are administered at the hospital before the infant’s discharge. States may require certain screenings to be performed more than once. Documentation of the tests performed and the results guides care of the child and establishes compliance with mandated screening.

The Bright Futures guidelines recommend that a clin- ical risk assessment for lead exposure be performed for infants at 6 and 9 months of age with blood lead testing to follow if positive. The guidelines also recommend that children who are enrolled in Medicaid, living in housing built before 1978, or living in high-risk areas as defined by the state or local health departments be screened for lead at 12 and 24 months of age. Public health authorities in each state are responsible for setting state and local policies.

There are numerous developmental tests that can be used to screen for developmental delay. Some are aimed at parents, whereas others are completed by health-care providers. The Denver Developmental Screening Test II (DDST-II) is a 125-item standardized measure that is designed to determine whether a child’s development is within the normal range. It includes a set of questions for parents and tests for the child on 20 simple tasks and items that fall into four sectors: personal-social (25 items), fine motor adaptive (29 items), language (39 items), and gross motor (32 items). The number of items administered during an assessment will vary with the child’s age and ability. The DDST-II scoring process, which is described in the screening manual, requires that the individual test items be interpreted before the entire test is interpreted. Screeners must be properly trained and pass a proficiency test before using the DDST-II for clinical purposes. The test was previously marketed by Denver Developmental Materials, Inc., in Denver, Colorado, hence the name. As of June 8, 2015, the company has closed. However, the test, manuals, and other materials are available at no cost online at www.DenverII.com. The test can be used in electronic medical records (EMRs) for free.

The Bayley Scales of Infant and Toddler Develop- ment, Third edition (2009), also known as Bayley-III, is recognized as one of the most comprehensive tools to assess children from 1 month of age and older. With Bayley-III, it is possible to obtain detailed information even from nonverbal children as to their functioning. Children are assessed in the five key developmental domains of cognition, language, social-emotional, motor, and adaptive behavior. Bayley-III identifies infant and toddler strengths and competencies as well as weaknesses. It also provides a valid and reliable measure of a child’s abilities, in addition to giving comparison data for chil- dren with high-incidence clinical diagnoses. It takes between 45 and 60 minutes to administer. A specific kit must be purchased to administer the Bayley-III.

One tool that parents can complete is the Par- ents’ Evaluation of Developmental Status (2007), or PEDS. PEDS contains 10 open-ended questions that elicit parents’ concerns about their child. It is both an evidence-based surveillance tool and a screening test. PEDS can be used from birth to 8 years of age. It takes just a few minutes to administer and score if conducted as an interview. Less time is required if parents complete the questionnaire while waiting or at home before the visit. There is also a version that is used to assess attainment of developmental mile- stones, known as PEDS-DM. These tools are available in English, Spanish, and Vietnamese. Information is readily available at www.pedstest.com.

Another screening tool that uses parent reporting is the Ages and Stages Questionnaires, Third edition

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Example 5.1 shows one way to document parental refusal.

EXAMPLE 5.1

L.M. accompanies her 12-year-old daughter H.M. today. I recommended administration of human papillomavirus vaccine (HPV) in accordance to CDC guidelines. L.M. stated, “I don’t want H.M. to have the vaccine.” L.M. states she doesn’t believe the vaccine is necessar y be- cause H.M. is not sexually active and that “there are too many vaccines.” I discussed with L.M. and H.M. reasons for the vaccine, including prevention of HPV-associated genital war ts and cervical, vulvar, vaginal, anal, and throat cancers. We discussed specifically that HPV vaccination can prevent most cases of cervical cancer. H.M. has no contraindications to receiving the vaccine. I discussed with L.M. and H.M. possible mild side effects of redness, swelling, and discomfor t at the injection site, fever, head- ache, and, rarely, severe allergic reaction; also discussed that benefits of preventing HPV-associated conditions outweigh these risks. I provided VIS on HPV vaccine (12/2/2016) and discussed the information on the VIS with L.M.; however, she refuses vaccination today.

You should revisit the immunization discussion at each subsequent appointment and carefully document the discussion. For children who are unimmunized or only partially immunized, some providers may want to flag the chart as a reminder to revisit the immu- nization discussion as well as to alert the provider about missed immunizations when considering the evaluation of future illness, especially young children with fevers of unknown origin. The AAP provides a Refusal to Vaccinate Form, accessible at www.aap.org/ en-us/Documents/immunization_refusaltovaccinate. pdf. Although the form should not be considered a legal document without advice from a lawyer, it may be used as a template for documentation of parental refusal. If a parent refuses to sign the form, then you should document such refusal, along with the name of a witness to the refusal, in the medical record.

Anticipatory Guidance Anticipatory guidance refers to specific topics that should be discussed with parents and caregivers of pediatric patients at age-appropriate levels. As children grow and develop, we anticipate that they will be involved in certain activities. For instance, many children learn to ride bicycles around 4 to 5 years of age. In anticipation of this, health-care providers should educate parents and caregivers to talk to the child about bicycle safety, wearing a helmet, wearing reflective clothing, and so forth. Table 5-1 presents topics that you should address with parents and caregivers based on the age of the child.

Assessing Vaccination Status Every pediatric and adolescent visit, whether for preventive care or evaluation of an illness or injury, is an opportunity to assess the child’s vaccination his- tory and determine whether vaccinations need to be administered. The CDC and the National Immuniza- tion Program publish recommendations for childhood (birth to 6 years of age) and adolescent (7 to 18 years of age) immunizations. They also publish a catch-up schedule for children who were not immunized at the recommended ages. The recommendations are updated annually; visit the CDC website at www.cdc.gov/vac- cines/schedules/index.html to obtain the most current schedule. The National Childhood Vaccine Injury Act (NCVIA) of 1986 and the CDC require health-care providers to document the date of vaccine administra- tion; vaccine manufacturer and lot number; name and business address of the health-care professional who administered the vaccine; and the Vaccine Information Statement (VIS) version date and date the VIS was provided to the parent/guardian. Additionally, the AAP recommends documentation of site and route of administration, vaccine expiration date, and a statement indicating that the VIS was discussed with the parent. VISs are accessible at www.cdc.gov/vaccines/hcp/vis/ index.html. VISs must be produced by the CDC and cannot be altered. Health-care providers may add the name, address, and other information of their practice, but substantive changes are not acceptable. The most current VIS must be given prior to administration of every dose of the vaccine (including each dose of a multidose series).

Parental refusal of vaccines is a growing concern for the increased occurrence of vaccine-preventable diseases in children. Vaccines play a vital role in preventing diseases in children, so it is crucial that health-care professionals understand the reasons that parents are hesitant or refuse to vaccinate their children. Although there are no federal laws regarding vaccine administration, each state has laws in place dictating which vaccinations are required for children prior to entering schools.

MEDICOLEGAL ALERT !

If a parent refuses a recommended vaccine and the child later develops the disease, the issue of profes- sional liability can arise. Therefore, it is essential that you document the parent’s refusal. Your documentation should indicate that the parent was informed of why the vaccine is recommended, the risks and benefits of vac- cination, possible consequences of not vaccinating, and any patient educational materials provided.

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Table 5-1 Age-Specific Anticipatory Guidance

Age at Visit Topics to Discuss Birth to 2 weeks

Good parenting practices; postpartum adjustment; infant care/sleep positioning; injury prevention; closeness with the baby; individuality of infants; breastfeeding or bottle feeding; signs of illness; Emergency/911; gun safety; drowning prevention; choking prevention; car/car seat safety (rear-facing); shaken baby prevention; safe bathing/water temperature; passive smoke; safety at home/childproofing; sun safety; pacifier use; bottle propping; infant bonding; support systems/resources; infant crying/ appropriate interventions

1 month Injury prevention; sleep practices; sleep positioning; Emergency/911; gun safety; drowning prevention; choking prevention; car/car seat safety (rear-facing); shaken baby prevention; infant development; when to call the doctor; infant care

2 months Injury prevention; sleep positioning/practices; fever education; family relationships; other child care providers; talking to the baby; pacifier use; bottle tooth decay; Emergency/911; gun safety; drowning prevention; choking prevention; car/car seat safety (rear-facing); shaken baby prevention; reading to baby

4 months Injury prevention; choking, aspiration; teething; solid foods; sleep positioning; thumb sucking; baby-proofing the home; appropriate child care providers; Emergency/911; gun safety; drowning prevention; choking prevention; car/car seat safety (rear-facing); shaken baby prevention; safe bathing/water temperature; passive smoke; safety at home/childproofing; sun safety; pacifier use; bottle propping; infant bonding; support systems/resources; infant crying/appropriate interventions; discuss child temperament; establish daily routines/infant regulation; establish nighttime sleep routine/sleep through night; parent reads to child

6 months Injury prevention; using a cup; finger foods; no bottle in bed; pool and tub safety; teething; poisons/ipecac; nutrition; sleep positioning; Emergency/911; gun safety; drowning prevention; choking prevention; car/ car seat safety (rear-facing); shaken baby prevention; passive smoke; safety at home/childproofing; sun safety; refrain from jump seat/walker ; sleep/wake cycle; introduce cup; begin using high chair ; wary of strangers; introduce board books; read to child

9–12 months Baby-proofing the home and pool; shoes for protection, not support; sleep; discipline; praise; dental hygiene; Emergency/911; gun safety; drowning prevention; choking prevention/soft texture finger foods/self-feeding; car/car seat safety (rear-facing); shaken baby prevention; safe bathing/water temperature; passive smoke; safety at home/childproofing; sun safety; sleep/wake cycle; TV screen time; exploration/learning; redirection/positive parenting; language/read to child/introduce board books; follow child’s lead in play; parent communicates to child “what things are” (ball, cat, etc.); ignore tantrums/give attention to positive behaviors

15–18 months Safety; sleeping; dental hygiene; sibling interaction; toilet training; Emergency/911; gun safety; drowning prevention; choking prevention/soft texture finger foods; snacks; aspiration; no more bottles; car/car seat safety (rear-facing); shaken baby prevention; safe bathing/water temperature; passive smoke; safety at home/childproofing; sun safety; helmet use; growing independence; tantrums; defiant behavior/offer child choices; gentle limit setting/redirection/safety; reading/parent asks child “What’s that?”; follow child’s lead in play; offer opportunity to scribble/explore; encourage expression of wide range of emotions; never leave toddler alone

2–3 years Decreased appetite, brushing teeth; toilet training; reading to the child; independence/dependence; car, home, and swimming pool safety; preschool; control of TV viewing; Emergency/911; gun safety; passive smoke; safety at home/childproofing; sun safety; sports/helmet use; establish daily routine; discipline/ redirection/praise; provide opportunities for success/choice; praise for effort/success; encourage/ support wide range of emotions; read to child; family adjustment/parent responds positively to child; manage anger; “monster” fear ; frustration/hitting/biting/impulse control; separates easily from parent; objects to major change in routine; shows interest in other children

4–5 years Preschool and school readiness (attention span, easy separation from parents); seat belts; street safety; ensuring the child knows his or her full name, address, and telephone number; household chores; no playing with matches; sexual curiosity; good and bad touches; kindness to animals; positive discipline/ redirecting; allowing child to play independently; begins to agree with rules; dictates story to adults; listens to authority figure; follows instructions

6–9 years Water, seat belts, skateboard, and bicycle safety; dental hygiene; peer relations; nutrition; limit setting; regular physical activity; parental role model; communication; fighting/bullying; street safety; TV screen time; positive discipline/redirecting; provide opportunities for social interaction; age-appropriate chores; daily reading; smoke-free environment

10–14 years Safety issues; nutrition; dental hygiene; peer pressure; puberty; safe sex/contraception/STD prevention; communication; safety rules with adults; monitor TV/computer time; peer refusal skills; self-control; depression/anxiety; tobacco/alcohol/drugs/prescription drugs/inhalants; risks of tattoos/piercing; after-school activities/supervision; educational goals/activities

15–18 years Safety issues; dental hygiene; safe sex/contraception/STD prevention; availability of family planning services; sexual orientation/dating; peer pressure, motor vehicle safety; sports safety; staying in school; after-school activities/supervision; educational goals/activities; safety rules with adults; monitor TV/ computer time; peer refusal skills; self-control; depression/anxiety; tobacco/alcohol/drugs/prescription drugs/ inhalants; risks of tattoos/piercing; violence prevention/gun safety/bullying; drowning/sun safety; car/seat belt/ driving safety; age-appropriate limits; social interaction; job/career planning; community involvement

Adapted from Early Periodic Screening Diagnosis and Treatment (EPSDT) program guidelines. More information is available at www.medicaid .gov/medicaid/benefits/epsdt/index.html. State specific forms are available at https://eclkc.ohs.acf.hhs.gov/hslc/states/epsdt.

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Specific screening tools have been developed for gathering the psychosocial history of adolescents. One commonly used tool can be remembered by the mne- monic HEEADSSS, which stands for home, education/ employment, eating, activities, drugs, sexuality, suicide/ depression, and safety. Henry Berman, MD, developed the original HEADS questionnaire in 1972. In 1985, it was expanded by Drs. Cohen and Goldering to HEADSS (adding suicide/depression screening), and this version was used for nearly 20 years. In 2004, it was updated again to address morbidity and mortality factors. The second “E” (eating) was added to encourage exploration of eating habits and screen for obesity and the third “S” (safety) to screen for unintentional injury and violence. Since the second version of HEEADSSS was released, nearly all teenagers have obtained access to the Internet and three-quarters of them use cell phones and send text messages. This utilization of media profoundly affects the lives of adolescents; media may now contribute to 10% to 20% of any specific health problem. Thus, questions on media use are critically important and are included in the HEEADSSS 3.0 update. The questions that comprise the HEEADSSS assessment are shown in Figure 5-4; notice that questions are identified as “first line” and “if time permits or if a situation warrants exploration.” Whenever possible, you should conduct the interview without the presence of parents, family members, or other involved adults. Regardless of the tool used, documentation of the psychosocial history is important to identify and address situations or behaviors that pose a risk for the adolescent.

Three out of four adolescent deaths are caused by un- intentional injury (e.g., motor vehicle crashes, drownings, poisonings, burns) and violence (e.g., homicide, suicide). Risk factor screening should include questioning about violence—either as an observer, a victim, or an offender. The FISTS mnemonic is helpful to remember screening questions related to fights, injuries, sexual violence, threats, and self-defense strategies. Specific questions for each of these categories are shown in Figure 5-5.

Unfortunately, children and adolescents may also be the targets of intentional violence. Child abuse is one of the leading causes of injury-related infant and child mortality. The Child Abuse Prevention and Treatment Act (CAPTA) defines abuse as a recent act or failure to act that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk for serious harm; involves a child; and is carried out by a parent or caregiver who is responsible for the child’s welfare. Four types of abuse are generally recognized: neglect, physical abuse, sexual abuse, and emotional abuse. Typically, these types of abuse are found more in combination than alone. Each state is responsible for defining child abuse and maltreatment within its own civil and criminal codes.

The specific anticipatory guidance topics that should be discussed at each age-specific visit are incorporated into the EPSDT and AAP forms. Be sure to document which topics are discussed with the parent or caregiver.

Risk Factor Identification For infants and younger children, risk factors for developing diseases or conditions often are related to the mother’s health during pregnancy. Therefore, a maternal history should be documented for all children 2 years of age or younger and may be indicated in older children if there is concern for developmental delay or if the child has physical abnormalities. Details of the maternal history are discussed in Chapter 4 and can be found in Table 4-1.

Data show that health risks in adolescents are more social in origin than medical. The American Medical Association’s Department of Adolescent Health developed the Guidelines for Adolescent Preventive Services (GAPS) with the goal of im- proving health-care delivery to adolescents using primary and secondary interventions to prevent and reduce adolescent morbidity and mortality. The use of GAPS enables you as the health-care provider to restructure the visit from a focus on traditional assess- ment of wellness to identification and treatment of at-risk behaviors, such as drinking, unprotected sex, nicotine use, or thoughtless or careless approaches to life. GAPS consists of 24 topics that encompass health-care delivery, health guidance, screening, and immunizations.

Electronic nicotine delivery systems (ENDS), such as electronic cigarettes (“e-cigarettes”), have been commercially available since 2004. The use of e-cigarettes may be referred to as vaping. Youth often believe that e-cigarettes are safer than conventional tobacco use, and they find e-cigarettes easy to conceal around adults. Studies show that youth are decreasing their use of conventional cigarettes while increasing use of e-cigarettes. Youth who were at lowest risk of conventional cigarette use are becoming conventional cigarette users after initiating with e-cigarettes. In 2015, more teens used e-cigarettes than regular cigarettes. You should incorporate screening for ENDS use and exposure into the screening for tobacco use. Because ENDS products vary widely and are referred to by many names, ask about use of these products by using specific names (e.g., electronic cigarettes, e-cigarettes, e-cigs, electronic cigars, electronic hookah, e-hookah, hookah sticks, personal vaporizers, mechanical mods, vape pens, vaping devices). As part of tobacco-use prevention counseling, you should include preven- tion counseling about the known hazards of ENDS and the importance of not initiating use of any nicotine-containing products.

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Home Who lives with you? Where do you live? Do you have your own room? What are relationships like at home? To whom are you closest at home? To whom can you talk at home? Is there anyone new at home? Has someone left recently? Have you moved recently? Have you ever had to live away from home? If yes, why? • Have you ever run away? If yes, why? • Is there any physical violence at home?

Education and Employment What are your favorite subjects at school? Your least favorite subjects? How are your grades? Any recent changes? Any dramatic changes in the past? Have you changed schools in the past few years? What are your future education/employment plans/goals? Are you working? Where? How much? • Tell me about your friends at school. • Is your school a safe place? Why or why not? • Have you ever had to repeat a class? Have you ever had to repeat a grade? • Have you ever been suspended? Expelled? Have you ever considered dropping out? • How well do you get along with the people at school? At work? • Have your responsibilities at work increased? Do you feel connected to your school? Do you feel as if you belong? Are there adults at your school you feel you could talk to about something important? Who?

Eating What do you like and not like about your body? Have there been any recent changes in your weight? Have you dieted in the last year? How? How often? Have you done anything else to try to manage your weight? How much exercise do you get in an average day? Week? What do you think would be a healthy diet? How does that compare to your current eating patterns? • Do you worry about your weight? How often? • Do you eat at home in front of the TV? Computer? • Does it ever seem as though your eating is out of control? • Have you ever made yourself throw up on purpose to control your weight? • Have you ever taken diet pills? What would it be like if you gained (lost) 10 pounds?

Activities What do you and your friends do for fun? (with whom, where, and when?) What do you and your family do for fun? (with whom, where, and when?) Do you participate in any sports or other activities? • Do you have any hobbies? • Do you read for fun? What? • How much TV do you watch in a week? How about video or computer games? • What music do you like to listen to?

Drugs Do any of your friends use tobacco? Alcohol? Other drugs? Does anyone in your family use tobacco? Alcohol? Other drugs? Do you use tobacco? Alcohol? Other drugs? Is there any history of alcohol or drug problems in your family? Does anyone at home use tobacco? • Do you ever drink or use drugs when you’re alone? (Assess frequency, intensity, patterns of use or abuse, and how

youth obtains or pays for drugs, alcohol, or tobacco)

Sexuality Have you ever been in a romantic relationship? Tell me about the people that you’ve dated. OR Tell me about your sex life. Have any of your relationships ever been sexual relationships? What does the term “safe sex” mean to you? • Are you interested in boys? Girls? Both? • Have you ever been forced or pressured into doing something sexual that you didn’t want to do? • Have you ever been touched sexually in a way that you didn’t want? • Have you ever been raped on a date or any other time? • How many sexual partners have you had altogether?

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Figure 5-5 FISTS screening questions.

Fighting: • How many fights have you been in during the past year? • When was your last fight?

Injuries: • Have you ever been injured in a fight? • Have you ever injured someone else in a fight?

Sexual Violence: • Has your partner ever hit you? • Have you ever hit (hurt) your partner? • Have you ever been forced to have sex against your will? • Do you think that couples can stay in love when one partner makes the other one afraid?

Threats: • Has someone carrying a weapon ever threatened you? • What happened? • Has anything changed since then to make you feel safer?

Self-Defense • What do you do if someone tries to pick a fight with you? • Have you ever carried a weapon in self-defense?

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• Have you ever been pregnant or worried that you might be pregnant? (females) • Have you ever gotten someone pregnant or worried that that might have happened? (males) • What are you using for birth control? Are you satisfied with your method? • Do you use condoms every time you have intercourse? • Does anything ever get in the way of always using a condom? • Have you ever had a sexually transmitted disease or worried that you had an STD?

Suicide and Depression Do you feel sad or down more than usual? Do you find yourself crying more than usual? Are you “bored” all the time? Are you having trouble getting to sleep? Have you thought a lot about hurting yourself or someone else? • Does it seem that you’ve lost interest in things that you used to really enjoy? • Do you find yourself spending less and less time with friends? • Would you rather just be by yourself most of the time? • Have you ever tried to kill yourself? • Have you ever had to hurt yourself (by cutting yourself, for example) to calm down or feel better? • Have you started using alcohol or drugs to help you relax, calm down, or feel better?

Safety Have you ever been seriously injured? (How?) How about anyone else you know? Do you always wear a seat belt in the car? Have you ever ridden with a driver who was drunk or high? When? How often? Do you use safety equipment for sports and/or other physical activities (for example, helmets for bicycling or skateboarding)? Is there any violence in your home? Does the violence ever get physical? Is there a lot of violence at your school? In your neighborhood? Among your friends? Have you ever been physically or sexually abused? • Have you ever been in a car or motorcycle accident? (What happened?) • Have you ever been picked on or bullied? Is that still a problem? • Have you gotten into physical fights in school or your neighborhood? Are you still getting into fights? • Have you ever felt that you had to carry a knife, gun, or other weapon to protect yourself? Do you still feel that way?

Italics = essential questions • Bulleted items = as time permits Bold italics = optional or when situation requires

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Figure 5-4 The HEEADSSS psychosocial interview for adolescents.

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Chapter 5 Pediatric Preventive Care Visits | 105

illness, or other). Questions ask if the patient experi- enced any of the traumatic experiences prior to the age of 17 and, if a positive response, includes follow-up questions to assess the individual’s understanding of his or her childhood trauma. It takes approximately 5 minutes to complete the questionnaire. The results are reported as severity classifications of none or minimal, low to moderate, moderate to severe, and severe to extreme.

The Youth at Risk Screening Questionnaire is directed at parents or adult caregivers. A list of 51 behaviors is given, and parents are asked to indicate if the item describes a youth they are concerned about. Each item is assigned a point value of 1, 5, 10, 15, or 20. The total score reflects the level of risk that the youth’s behavior will escalate without intervention. A score of 5 to 16 indicates low risk; 17 to 32, moderate risk; 33 to 84, high risk; and 85 or more, extremely high risk. The questionnaire may be completed online; once submitted, a results page appears along with a brief list of resources, helpful interpretation material, and additional screening resources. The online ver- sion is available at www.scribd.com/doc/215077310/ youth-at-risk-screening-questionnaire.

Another screening tool is the Childhood Maltreatment Interview Schedule—Short Form (CMIS-SF). The short form was adapted from the full CMIS, published by John Briere, PhD, in 1992. The form is intended to be

The most common type of abuse is neglect. Neglect is the failure of a parent, guardian, or other caregiver to provide for a child’s basic needs. Physical abuse is nonaccidental physical injury that is inflicted by a parent, caregiver, or other person who has responsibility for the child. Such injury is considered abuse regardless of whether the caregiver intended to hurt the child. Sexual abuse includes any sexually explicit conduct or simulation thereof for the purpose of producing a visual depiction of such conduct or the rape, molestation, prostitution, or other form of sexual exploitation of children or incest with children. Emotional abuse is a pattern of behavior that impairs a child’s emotional development or sense of self-worth. This may include constant criticism, threats, or rejection as well as withholding love, support, or guidance. Emotional abuse is often difficult to prove and, therefore, child protective services may not be able to intervene without evidence of harm or mental injury to the child. Emotional abuse is almost always present when other forms are identified. Table 5-2, adapted from the Child Welfare Information Gateway, summarizes the signs that suggest abuse based on characteristics of the child or the parent or adult caregiver.

If any type of abuse is suspected, there are stan- dardized tools available to assist you with additional screening and documentation. The Childhood Trauma Questionnaire is a brief survey of six early traumatic experiences (death, divorce, violence, sexual abuse,

Type of Abuse Child Characteristics Parent/Adult Characteristics Neglect Frequently absent from school; begs or steals food or money;

lacks needed medical or dental care, immunizations, or glasses; is consistently dirty or has severe body odor; lacks sufficient clothing for the weather; states that there is no one at home to provide care

Appears indifferent to the child; seems apathetic or depressed; behaves irrationally or in a bizarre manner; is abusing alcohol or drugs

Physical Has unexplained burns, bites, bruises, broken bones, or black eyes; has fading bruising or other marks noticeable after an absence from school; seems frightened of the parents and protests or cries when it is time to go home; shrinks at the approach of adults; reports injury by a parent or another adult caregiver

Offers conflicting, unconvincing, or no explanations for the child’s injury; describes the child as “evil” or in some other very negative way; uses harsh physical discipline with the child; has a history of abuse as a child

Sexual Has difficulty walking or sitting; suddenly refuses to change for gym or to participate in physical activities; reports nightmares or bedwetting; experiences a sudden change in appetite; demonstrates bizarre, sophisticated, or unusual sexual knowledge or behavior ; runs away; becomes pregnant or contracts a sexually transmitted disease, particularly if younger than 14 years; reports sexual abuse by a parent or another adult caregiver

Is unduly protective of the child or severely limits the child’s contact with other children, especially of the opposite sex; is secretive and isolated; is jealous or controlling with family members

Emotional Shows extremes in behavior, such as overly compliant or demanding, extreme passivity or aggression; is either inappropriately adult or infantile; is delayed in physical or emotional development; has attempted suicide; reports a lack of attachment to the parent

Constantly blames, belittles, or berates the child; is unconcerned about the child and refuses to consider offers of help for the child’s problems; overtly rejects the child

Adapted from Child Welfare Information Gateway.

Table 5-2 Signs and Symptoms of Child Abuse

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106 | Guide to Clinical Documentation

Table 5-4 shows neurological reflexes that should be tested and documented during infancy. If you detect any abnormalities on physical examination, be sure that your assessment and plan address what additional testing, if any, is indicated and what follow-up will be needed.

Pediatric Sports Preparticipation Physical Examination Many pediatric and adolescent patients will want to participate in sports activities and usually will need medical clearance to do so. The preparticipation physical examination may be the only time a healthy adolescent will see a health-care provider, so it is important to include some age-appropriate screening questions and anticipatory guidance. A comprehen- sive medical history that includes questions about a personal and family history of cardiovascular disease is an important component of the preparticipation evaluation. You should document any personal history of congenital or acquired heart disease as well as a his- tory of hypertension or murmurs. Symptoms of chest discomfort, shortness of breath, palpitations, syncope, or near-syncope with exercise are important. A known family history of hypertrophic cardiomyopathy, Marfan syndrome, or atherosclerosis, as well as a history of unexplained sudden death in family members younger than 50 years of age, are all of concern. Asking about the use of cocaine or anabolic steroids is particularly appropriate. You should complete all components of an age-specific physical examination with particular emphasis on the respiratory, cardiac, and musculoskel- etal systems. The cardiac examination should include auscultation with provocative maneuvers to screen for hypertrophic cardiomyopathy because this is the most common cause of sudden death in young male athletes. The recommended musculoskeletal examination is provided in Table 5-5.

Young women are less likely to experience sudden death on the athletic field than young men. In female athletes, however, several predispositions should be considered. Anorexia nervosa and other eating disorders are more common among female athletes than among male athletes. Screening questions about desires to change weight or displeasure with body habitus iden- tify many of these women. Female runners are more likely to develop stress fractures than are male runners. Osteoporosis occurs in amenorrheic female athletes, and this finding should prompt further consideration of the possibility of an eating disorder.

completed by interviewing the patient rather than by self-report. Questions typically start with the phrase, “Before age 17 . . .” and go on to ask about specific events that may have occurred, such as a parent having problems with drugs or alcohol or an adult yelling at, insulting, ridiculing, or humiliating the child. If the response is positive, then you would ask follow-up questions about how often, who was involved, and so forth. The questions explore psychological, emotional, and physical abuse.

You as a health-care provider are required by law to make a report of suspected child maltreatment. For more information, see the Child Welfare Information Gateway publication, Mandatory Reporters of Child Abuse and Neglect at www.childwelfare.gov/topics/sys- temwide/laws-policies/statutes/manda. An additional resource for information and referral is the Childhelp® National Child Abuse Hotline (1-800-4-A-CHILD or 1-800-422-4453). Documentation should include the findings that indicate possible abuse, the date the report is made, the person to whom the report is made and his or her title, and the agency (such as police or child protective services). A copy of any written report should be incorporated into the child’s permanent medical record.

Age-Specific Physical Examinations Documentation of a newborn physical examination is presented in Chapter 4. The content of the physical examination of pediatric patients includes each of the systems shown in Table 2-1. You are encouraged to follow the “head-to-toe” order when conducting a physical examination, but exceptions are made for pediatric patients. If possible, you should auscultate the lungs, heart, and abdomen when the child is quiet and not crying. Some components of the examination are likely to elicit crying, such as examining the ears and the oropharynx and conducting parts of the mus- culoskeletal examination. Regardless of the order in which the examination is performed, you should always document in the order shown in Table 2-5.

There are many excellent references available that teach physical examination techniques. It is beyond the scope of this book to present the entire physical examination for all the age-specific well-child visits. Once a child reaches school age, the physical exam- ination is similar to an adult physical examination. Table 5-3 presents a summary of physical examination components that should be documented specifically when performing infant and toddler examinations.

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Chapter 5 Pediatric Preventive Care Visits | 107

System Examination Component Age Comments Skin Color for jaundice,

cyanosis, other discoloration

All ages; most critical in neonate Jaundice that appears within the first 24 hours of birth is likely to be pathological jaundice due to hemolytic disease of newborn; jaundice that persists beyond 2–3 weeks should raise suspicions of biliary obstruction or liver disease; important to document presence or absence of Mongolian spot because it may be misdiagnosed as ecchymosis, raising concern of intentional injury

Rash or lesions All ages Many benign skin lesions and rashes common in childhood HEENT Head Birth until sutures and fontanelles

closed Anterior fontanelle at birth measures 4–6 cm in

diameter, closes between 4 and 26 months of age; posterior measures 1–2 cm at birth, usually closes by 2 months of age

Eyes Birth to 24 months

Red reflex Absence may indicate congenital glaucoma, cataract, retinal detachment, or retinoblastoma

Strabismus If present after 10 days of age, may indicate poor vision or disease of the central nervous system

Mouth Teeth First eruption, then throughout life First eruption at about 6 months, then usually a tooth each

month until 2 years, 2 months of age Tonsils All ages May be enlarged in healthy child; peak growth of

tonsillar tissue between 8 and 16 years of age Palate Most critical in infancy Document whether any cleft or bifid uvula Neck Lymph nodes All ages May not be palpable until toddler Nuchal rigidity All ages Not a reliable sign of meningeal irritation until after age

of 2 years Respiratory Lung sounds Every visit Listen for a cause of any abnormal breath sounds Cardiovascular Heart rate, rhythm, and

sounds Every visit Document character of any murmur present

and include in assessment and plan; Still murmur common in preschool- and school-age children but is usually benign

Gastrointestinal Umbilical cord Birth until healed Document that parent/caregiver was educated on

cord care Bowel sounds Every visit Absence of bowel sounds is always abnormal; look

for cause Rectum Birth Assess and document patency Male Genitourinary Testes Most critical at birth Both testes should be descended; if cannot palpate

both, consultation is warranted Scrotum Most critical at birth Inspect for masses; if present, document whether

transparent on transillumination; hydroceles common in newborns

Penis, including foreskin All ages Nonretractable at birth but must visualize the urinary meatus and document the presence or absence of hypospadias; document sexual maturity using Tanner stages1

Table 5-3 Documentation of Important Components of Age-Specific Physical Examinations

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System Examination Component Age Comments Female Genitourinary Breasts All ages In newborn, may express white liquid for up to 2 weeks;

document breast development External genitalia All ages Often a milky-white or blood-tinged vaginal discharge in

first few weeks; inspect hymen; document development of external genitalia using Tanner stages

Musculoskeletal Clavicle Birth Fracture may occur during delivery Spine Birth through adolescence Assess for spina bifida at birth; screen for scoliosis until

adolescence Hips Birth through 6 months Document findings of Barlow and Ortolani tests; if there

is congenital hip dysplasia, the best outcome is when treatment is initiated in the first 6 weeks of life

Neurological Cranial nerves Birth to 24 months, then annually

if normal Consult physical examination reference for strategies to

assess cranial nerves in newborns, infants, and young children

Reflexes Many reflexes present at birth will disappear in infancy; see Table 5-4 for reflexes that should be tested in infancy

1Refer to a physical diagnosis reference for explanation and more information.

Table 5-3 Documentation of Important Components of Age-Specific Physical Examinations—Cont’d

Reflex Ages Comments Palmar grasp Birth to 3–4 months Persistence beyond 4 months suggests cerebral dysfunction Plantar grasp Birth to 6–8 months Persistence beyond 8 months suggests cerebral dysfunction Moro (startle reflex) Birth to 4–6 months Persistence beyond 4 months suggests neurological disease;

persistence beyond 6 months is strongly suggestive of disease; asymmetrical response suggests fracture of clavicle or humerus or injury to brachial plexus

Asymmetrical tonic neck Birth to 2 months Persistence beyond 2 months suggests neurological disease Rooting Birth to 3–4 months Absence of rooting indicates severe disease of the general

or central nervous system Placing and stepping 4 days after birth, variable

age to disappear Absence of placing may indicate paralysis; babies born by breech

delivery may not have placing reflex Parachute Develops around 4–6

months and does not disappear

Delay in appearance may predict future delays in voluntary motor development

Trunk incurvation (Galant reflex)

Birth to 2 months Absence suggests a transverse spinal cord lesion or injury

*Refer to a physical examination reference for a full description of each reflex and the maneuver necessary to elicit each one.

Table 5-4 Neurological Reflexes That Should Be Tested During Infancy*

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Chapter 5 Pediatric Preventive Care Visits | 109

the psychosocial history and risk assessment. Various screening tools are available to assist you in transitioning from a focus on traditional assessment of wellness to identification of and intervention for at-risk behaviors. It is imperative that you are knowledgeable of findings that raise concern for child abuse or maltreatment and aware of mandatory reporting guidelines for the state in which you practice. You should perform age-specific physical examinations with the goal of identifying any abnormalities that suggest disease, injury, or ill- ness. Careful management of any identified problems should focus on maintaining health and function to carry the patient into adulthood. The worksheets that follow will help reinforce concepts related to pediatric and adolescent preventive care visits. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation. You can follow documentation through the mother’s pregnancy and birth of the baby as well as the well-child visits.

Summary Preventive care visits with pediatric and adolescent pa- tients often provide the chance for you to interact with children who are well and can be quite enjoyable. In the absence of any chronic conditions, the visits are largely geared to developmental screening, risk assessment, health promotion and disease prevention, and antici- patory guidance. Documenting preventive care visits for pediatric and adolescent children is often facilitated by using standardized forms that aid in meeting federal and state guidelines. Documentation of anticipatory guidance provided at each visit is critical. Every visit is an opportunity to assess immunization status. If a parent or guardian refuses to consent to vaccination, then you must carefully document the refusal, as well as any discussion of risks and benefits of the vaccine, and any education provided. As a child ages and transitions into adolescence, much of the visit focuses on documenting

Examination Component and Maneuver Assessment Neck—move neck in all directions Range of motion Shoulders—shrug against resistance Strength of shoulder, neck, and trapezius muscles Arms—hold out to side and apply pressure Strength of deltoid muscle Arms—hold out to side, bend 90 degrees at elbows, raise

and lower arms External rotation and stability of glenohumeral joint

Arms—hold out straight, then bend and straighten elbow Range of motion of elbow Arms—hold down, bend 90 degrees at elbows, pronate

and supinate forearm Range of motion of elbows and wrists, muscle strength of

forearms and wrists Hand—make a fist, clench and then spread fingers Range of motion of fingers, strength and stability of joints

and muscles Squat and duck walk Range of motion of hips, knees, and ankles; strength and

stability of joints Stand straight with arms to side, back to examiner Symmetry, leg-length discrepancy Bend forward from waist with knees straight Scoliosis of spine Stand and raise up on toes and walk on heels Strength and stability of ankle joints; strength of calf muscles

Table 5-5 Musculoskeletal Portion of Sports Preparticipation Physical Examination

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Worksheet 5.1

Name

Review

1. List five components of pediatric preventive visits.

2. List three growth parameters that should be measured and documented from birth to 24 months of age.

3. At what age should documentation of BMI measurement begin?

4. Name three widely used resources available from the CDC.

5. List at least three tools that are used to screen children for achievement of developmental milestones.

6. Access http://babysfirsttest.org/newborn-screening/states and identify at least five newborn screening tests

mandated by the state in which you live.

7. You are performing a sports preparticipation physical on a 15-year-old boy. You review his immunization

record and notice that he is due to receive a tetanus and diphtheria booster ; however, his father refuses to

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consent for the vaccine. Access the Vaccine Information Sheet for tetanus and diphtheria at www.cdc.gov/

vaccines/hcp/vis/index.html and, using Example 5.1 as a guide, document the refusal.

8. For each of the ages listed, list at least three topics that should be discussed with parents/caregivers as part

of anticipatory guidance.

6 months:

2–3 years:

10–14 years:

9. What does the FISTS mnemonic stand for?

10. List the four recognized types of child abuse.

11. List at least two screening tools that can be used to assess for child abuse or maltreatment.

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12. List at least four topics that should be explored when taking the history of a child who presents for a

preparticipation sports examination.

13. What three systems should be emphasized when examining a child who presents for a preparticipation

sports examination?

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Worksheet 5.2

Name

Plotting Growth Measurements M.G. is brought in by her parents for a 24-month-old well-child visit. Shown next are measurements ob- tained at today’s visit, along with measurements from her 6-month and 12-month well-child visits. Plot each of these measurements on the growth charts provided.

6-month-old 12-month-old 24-month-old

Weight: 15 pounds 20 pounds 26 pounds

Length: 25 inches 28½ inches 33½ inches

Head circumference: 16½ inches 17½ inches 18½ inches

kg lb

2 kg lb

4 lb

95th

3Birth 6 9 12 15 18 21 24 27 30 33 36

Age (months)

90th

75th

50th

25th

10th 5th

Weight-for-age percentiles: Girls, birth to 36 months

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cm in.

105

100

cm in.

in. 42

17 in.

3Birth 6 9 12 15 18 21 24 27 30 33 36 Age (months)

Length-for-age percentiles: Girls, birth to 36 months

95th 90th

75th

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Indicate the percentile for each of the preceding measurements.

6-month-old 12-month-old 24-month-old

Weight: __________ ____________ ____________

Length: __________ ____________ ____________

Head circumference: __________ ____________ ____________

Consult a pediatric textbook or history and physical examination textbook and determine whether or not

these measurements are within normal limits.

cm in.

in.

3Birth 6 9 12 15 18 21 24 27 30 33 36 Age (months)

Head circumference-for-age percentiles: Girls, birth to 36 months

95th 90th 75th

50th

25th

10th 5th

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C.A. is a 24-month-old boy who is brought in for a well-child visit. Here are the measurements obtained at today’s visit, along with measurements from his 6-month and 12-month well-child visits. Plot each of these measurements on the growth charts provided.

6-month-old 12-month-old 24-month-old

Weight: 8.5 kg 10.4 kg 12 kg

Length: 68.5 cm 76 cm 86 cm

Head circumference: 44.4 cm 46.2 cm 47.6 cm

kg lb

2 kg lb

4 lb

3Birth 6 9 12 15 18 21 24 27 30 33 36 Age (months)

Weight-for-age percentiles: Boys, birth to 36 months

95th

90th

75th

50th

25th

10th 5th

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cm in.

105

100

cm in.

in. 42

17 in.

3Birth 6 9 12 15 18 21 24 27 30 33 36 Age (months)

Length-for-age percentiles: Boys, birth to 36 months

95th 90th

75th

50th

25th

10th 5th

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Indicate the percentile for each of the preceding measurements.

6-month-old 12-month-old 24-month-old

Weight: __________ ____________ ____________

Length: __________ ____________ ____________

Head circumference: __________ ____________ ____________

Consult a pediatric textbook or history and physical examination textbook and determine whether or not

these measurements are within normal limits.

cm in.

in.

3Birth 6 9 12 15 18 21 24 27 30 33 36 Age (months)

Head circumference-for-age percentiles: Boys, birth to 36 months

95th 90th 75th

50th

25th

10th

5th

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Worksheet 5.3

Name

Sample HEEADSSS Write-Up

Following is a sample HEEADSSS write-up for A. K., a 15-year-old patient who comes to the family practice of-

fice. After reading the write-up, answer the questions that follow. A. K. lives at home with her mother and two younger siblings. She visits her father every other weekend, and the father, stepmother, and one stepbrother live in that home. A. K. says she is very close to her mother and has a good relationship with her. Not as close to her father, but they “get along OK.” She does not get along well with her stepmother or stepbrother. A. K. is also close to her aunt and spends a lot of time at her home. A. K. feels that she has a good support system in her mom, aunt, and band director. A. K. is in the 9th grade at Ridgeline High School. She has never failed or repeated a grade. Grades are mostly Bs, some Cs last report card. She is in band and in several clubs. She worked this past summer as a lifeguard at a water park but does not work during the school year. A. K. volunteers as a dog-walker at the humane society and usually goes two Saturdays a month. Her father smokes and drinks alcohol but “isn’t a drunk.” Her mother used to smoke but quit a few years ago. A. K. has never tried a cigarette and says, “they are disgusting.” Some of her friends smoke, but she is not pressured by them and does not plan to start smoking. She has never experi- mented with drugs. A. K. has had three sexual partners—all male partners. She has talked to her mom about taking OCPs. A. K. says she understands that the pill will not protect her from STDs and says she hopes her partner will use a condom. She knows of someone from her school who committed suicide last year, but she says she can’t imagine ever doing that. Denies feeling consistently or frequently sad or down. Has never contemplated suicide and thinks it is “stupid.” A. K. wears a seat belt regularly. She has a learner’s permit but no driver’s license yet. Rides her bike occasionally and doesn’t wear a helmet when riding. No guns in either of her parents’ homes. Knows of one boy who brings a knife to school, but she doesn’t hang out with him. Witnesses fights at school occasionally but has never been directly involved. Feels safe at home.

1. Based on the information in this write-up, list any risk factors that you identified for A. K.

2. Critically analyze the content of this write-up. Identify other topics or additional information that should

have been included in this write-up.

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3. Do you feel additional screening is needed at this time? Why or why not? If yes, what screening should be

done?

4. What anticipatory guidance should be provided to A. K.’s mother at this visit?

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Worksheet 5.4

Name

Abbreviations

These abbreviations were introduced in Chapter 5. Beside each, write the meaning as indicated by the contents

of this chapter.

AAP

BMI

CDC

DDST-II

ENDS

GAPS

HRSA

MCHB

NHANES

PEDS-DM

RUSP

WHO

ASQ-3

CAPTA

CMIS-SF

EMR

EPSDT

HPV

JAMA

NCVIA

PEDS

PKU

VIS

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125

Adult Preventive Care Visits LEARNING OUTCOMES

• Describe the major components of an adult preventive care visit. • Discuss the importance of documenting a patient’s personal and family medical history. • Identify several screening questionnaires used to identify tobacco, alcohol, and substance abuse. • State the five Ps of the sexual history. • Identify specific information that should be documented for the patient who is a victim of intimate

partner violence. • Explain the Occupational Safety and Health Administration’s mission, and describe occupational hazards

that should be identified. • List conditions that are screened for in the family history. • Identify the “red flags” in a family history. • Identify screening tests that are commonly recommended for all adults and additional gender-specific

screening tests for women and men. • Discuss the components of preconception care visits. • Identify vaccines recommended for adults.

Introduction According to the most recent National Ambulatory Medical Care Survey (2013), ambulatory medical care in physician offices is the largest and most widely used segment of the American health-care system. During 2013, an estimated 922.5 million visits were made to physician offices. New patients accounted for 16.3% of visits, whereas established patients accounted for 83.7%. Approximately 19.9% of all visits were for preventive care.

Preventive care is defined as medical care that focuses on disease prevention. This takes place at primary, secondary, and tertiary prevention levels. Primary prevention avoids the development of a disease. Most population-based health promotion activities, such as vaccines, immunization, and hand washing, are primary preventive measures. Secondary prevention activities are aimed at early disease detection, thereby increasing opportunities for interventions to prevent progression of the disease and emergence of symptoms. These activities include screening measures to detect a specific condition, such as using mammography to screen for breast cancer. Tertiary prevention aims to

eliminate, or at least delay, the onset of complica- tions and disability due to the disease. Most medical interventions fall into this category. One example of tertiary prevention is striving for euglycemic control in a patient with diabetes.

Health maintenance is a term that is often used interchangeably with preventive care. Health main- tenance is a guiding principle that emphasizes health promotion and disease prevention rather than the management of symptoms and illness. It includes the full array of counseling, screening, and other preventive services designed to minimize the risk for premature illness and death and to ensure optimal physical, mental, and emotional health throughout the natural life cycle.

It is far better to try to prevent a condition than to have to treat it. The cost of disease management creates a tremendous economic burden for government payers and private insurance carriers as well as society in general. In addition to the economic cost of disease, there is the physical and psychological impact on the quality of life of patients and their families. For these reasons, screening guidelines for certain conditions have been developed. The term screening refers to tests and exam- inations used to detect a disease, like cancer, in people

Chapter 6

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126 | Guide to Clinical Documentation

who do not have any symptoms. Current U.S. screening recommendations are focused on diseases that occur most frequently and that have the highest morbidity and mortality rates. Many federal and state agencies and specialty organizations, such as the American Heart Association (AHA) and the American Cancer Society (ACS), also publish guidelines for screening. Although many of the recommendations are the same, there are variations in frequency of screening. It is beyond the scope of this book to include all the recommendations that have been published; instead, the most generally accepted guidelines are summarized. The focus of this chapter is documenting preventive care visits for adult patients; prenatal care is discussed in Chapter 4; pediatric and adolescent preventive care is discussed in Chapter 5, and older adult preventive care is discussed in Chapter 7.

Documenting Preventive Care Components of a preventive care visit include the following: • Risk factor identification based on personal and

family health history • Appropriate laboratory and diagnostic screening

tests • Age- and gender-specific screening, including

preconception screening • Patient education and counseling • Assessment of vaccination status and administer-

ing vaccines as appropriate You may use preprinted forms, such as the adult medical history form shown in Figure 6-1, to collect much of the patient’s history, including personal and family medical history. If using such a form, it is important to review it thoroughly with the patient and obtain more information about any positive responses. Specifically document that the form was reviewed with the patient. Throughout the remainder of this chapter, several screening tools or questionnaires are referenced. Such tools are an excellent aid for obtaining and documenting important information during the preventive care visit.

When using printed forms or providing written material, be sure to assess your patients’ level of health literacy. The U.S. Department of Health and Human Services (HHS) defines health literacy as the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness. It is beyond the scope of this book to address this subject; however, information is widely available.

Risk Factor Identification Based on Personal History Often indications for screening are based on the patient’s age. For example, the ACS recommends that women 45 years of age and older have regular screening mammography. However, screening recommenda- tions may be different depending on certain personal risk factors. Therefore, a key purpose of obtaining the patient’s personal medical history is to identify conditions for which the patient is at risk and the screening measures appropriate for those conditions. Some risk factors are associated with personal habits, such as alcohol or tobacco use or dietary intake. It is important to determine whether these risk factors are present; recognize, however, that inquiring about risk factors could appear judgmental. Inform your patient that you need to ask some questions that could be sen- sitive in nature, and let the patient know that you ask these questions of all your patients. Approaching these matters in a nonjudgmental, professional, matter-of-fact manner should enhance patient disclosure of sensitive information. The following sections identify some of the risk factors that you should inquire about, and you should specifically document their presence or absence as part of the personal medical history.

Exercise Lack of exercise or a sedentary lifestyle is a risk factor for certain conditions, such as cardiovascular disease and diabetes, so you should encourage patients to exercise regularly. Document any information given to you by the patient related to his or her exercise habits. You should document the type of activity (e.g., walking, weight lift- ing, aerobics), frequency, and duration (e.g., 30 minutes every other day). The current recommendation is for moderate activity five or more days of the week for at least 30 minutes that encompasses a combination of cardiovascular and weight training.

Diet and Nutrition The goal of documenting a nutritional history is to help you identify dietary deficiencies or excesses and then educate your patient about how to improve his or her nutritional status. Assess dietary habits by asking the patient about a typical day’s food intake. Include number of meals per day; frequency of eating out and types of eating establishments frequented (such as fast food, restaurant, cafeteria); number of fruit and vegeta- ble servings per day; portion size, frequency, and type of protein (such as meat, poultry, seafood, dairy or soy products); and fiber intake. Determine the amounts of fat (especially saturated), sugar, and processed foods that the patient consumes each day. Instead of gathering this information by interviewing the patient,

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Chapter 6 Adult Preventive Care Visits | 127

To be completed by patient

(Continued)

Date: __/__/__ Name: _______________________________________ Age: _______ Date of birth: __/__/__ Male Female Mailing address: _______________________________________________________________________________________ Home phone: __________________________ Work phone: ________________________ Other phone: _________________ Emergency contact name and phone number: ________________________________________________________________ Employer’s name and address: ______________________________________________________________________________

Please list all the people living in your household and their relationship to you.

Name Age Relationship

Personal Health History: Do you have, or have you ever had, any of the following? (Check all boxes that apply.)

Allergies Anemia

Alcohol/ Drug addiction Arthritis Asthma

Back pain

Blood transfusion

Bowel problems Breathing problems Cancer (type ______) Depression Diabetes

Eye problems

Serious injury (type __________)

Heart problems High blood pressure High cholesterol Kidney problems Liver problems

Migraine headaches

Nerve problems Seizures

Skin problems

Stroke Thyroid problems Ulcers

Current Medications (please include prescription and over-the-counter medications):

Name of Medication Dose (mg) Taken how many times a day?

Please indicate if you have allergies to any of the following:

___ penicillin ___ sulfa ___ codeine ___ latex ___ vaccines ___ nuts ___ shellfish ___ nickel ___ contrast dye Other: ____________________________ If any food allergies, please list: _______________________________________________________________________________

Family History: (check all that apply)

Father Mother

Siblings

Grandparents

Alcoholism Asthma or allergies

Cancer (type)

Depression Diabetes Heart disease

High blood pressure

Stroke Cause of death

Age at death

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128 | Guide to Clinical Documentation

risk factor for many health problems. BMI is calculated by using the following formula:

Weight (kg) ÷ [height(m)]2 (Because height is commonly measured in centimeters, divide height in

centimeters by 100 to obtain height in meters.)

Weight (lb) ÷ [height (in.)]2 × 703

BMI calculators are readily available at many Inter- net sites. BMI tables, such as the adult table shown in Figure 6-2, are available from many sources. Different tables are used for children and teens. Four different categories have been identified based on the patient’s BMI: • Less than 18.5 = Underweight • 18.5 to 24.9 = Normal weight • 25 to 29.9 = Overweight • 30 or greater = Obesity

At the preventive visit, it is important to explore why the patient is obese. Teach the patient that this is a reversible risk factor, and encourage weight management, nutrition, and exercise. Recognition of the need for weight loss and accountability as well as support from you as the health-care provider remain key elements of patient success.

you may ask the patient to record all food intake for a predetermined amount of time. Then you should in- clude a copy of the food diary in the patient’s chart. If the patient follows a vegetarian diet, document which type (e.g., vegan, lacto-ovo vegetarian) and assess for nutritional inadequacies. Document the use of vitamins and supplements taken, if any. Document the amount of water and other beverages consumed. The quantity of caffeine consumed per day should be documented in standard units of measure, such as how many cups of coffee or tea, number of soft drinks, energy drinks, and amount of caffeine-containing foods.

Body Mass Index Obesity is a serious, chronic disease that is known to reduce life span, increase disability, and lead to many serious illnesses. Studies have confirmed a direct cor- relation between increases in body mass index (BMI) and increases in the prevalence of type 2 diabetes, hypertension, heart disease, stroke, and arthritis. The BMI is calculated based on the patient’s height and weight. Although these measurements are obtained as part of the physical examination rather than the history, it is important to review the BMI with every patient because being overweight or obese is a major

Figure 6-1 Adult medical history form.

Social History: Marital status: married single Tobacco use: none chew tobacco cigar/pipe cigarettes _____ packs/day for _____ years quit date ____ Alcohol use: none drinks/week ______ Type of drink ______________ other drug use (type) _________________ Exercise: daily ______ times/week Intensity: low medium high aerobic weight training Seat belt use: yes no Helmet or other safety measures: yes no

Immunizations/Screening Exams (date of most recent): hepatitis B _____ Pneumovax _____ tetanus _____ flu shot _____ stool for blood _____ chest x-ray _____ TB test ______ colonoscopy ______

Women only: Pap smear ____________ Any abnormal Pap smears? yes no Mammogram ___________ Any abnormal mammogram? yes no Do you perform breast self-exams? yes no If yes, how often? ______ Age you started your periods: _______ Are they regular? yes no Number of days: _______ Do you still have periods? yes no Have you ever taken hormone replacement therapy? yes no Have you had bone density testing? yes no If yes, when and where was most recent? ________________________ How many times have you been pregnant? ________ How many children do you have? ________ Number of vaginal deliveries: _________ Number of C-sections: ________

Men only: Prostate exam: ____________ Any abnormal prostate exams? yes no Testicular exam: ____________ Do you perform testicular self-exams? yes no

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Chapter 6 Adult Preventive Care Visits | 129

Figure 6-2 Adult body mass index table. (Courtesy Office of Disease Prevention and Health Promotion, https://health.gov/dietaryguidelines/dga2005/document/html/chapter3.htm)

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Tobacco Use Tobacco use is the leading preventable cause of premature death in the United States. It is estimated that directly or indirectly, tobacco causes more than 480,000 deaths annually, a figure that represents nearly 20% of all deaths. These deaths have been attributed to a number of conditions defined as tobacco-related, including heart disease (124,000 deaths), cancer (163,000), chronic obstructive pulmonary disease (100,000), and cerebrovascular accidents (CVA) (27,000). You should screen all patients for tobacco use. Document whether the tobacco use is smoked (cigarettes, pipe, cigar) or smokeless (snuff and chewing tobacco). Documentation

should include the amount used per day and how long the patient has been using tobacco. Usually cigarette use is reported as a pack-year history. This figure is determined by multiplying the number of packs per day (PPD) by the total number of years smoked. Pipe and cigar smoking is indicated by frequency per day. Document the use of smokeless tobacco as the number of cans or pouches used per day, or sometimes per week. It is important to educate a patient currently using any form of tobacco on the health risks associated with tobacco use and to document specifically the educa- tion provided. You should ask whether the patient is interested in quitting.

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130 | Guide to Clinical Documentation

shows how you could document a patient’s tobacco use and cessation education that you provide.

EXAMPLE 6.1

The patient chews tobacco, approximately one pouch every 2 days for the past 12 years. I discussed specific health risks associated with smokeless tobacco, including oral cancers (cancer of the throat, tongue, and lar ynx), leukoplakia, gum disease, cardiovascular disease, hyper- tension, and ear ly mor tality. Patient stated that he is not ready to quit. I advised patient that cessation aids are available should he desire to quit.

If the patient formerly smoked but has quit, document the year quit and the pack-year history. Take every opportunity to provide positive reinforcement to any patient who has quit smoking. Unfortunately, some patients who quit using tobacco products will start again, so ask about tobacco use at every visit.

Use Application Exercise 6.1 to practice calculating pack-year history.

Electronic nicotine delivery systems (ENDS), such as electronic cigarettes (“e-cigarettes”), have been available commercially since 2004. The use of e-cigarettes may be referred to as vaping. To date, the health effects of ENDS use have not been well studied, but the nico- tinergic effects are similar to traditional cigarettes. The potential harmful effects of vaping have led the Food and Drug Administration (FDA) to issue warnings regarding the risks of vaping; therefore, you should document the patient’s use of ENDS as part of the social history. As with traditional tobacco use, it is not enough simply to document that a patient “uses e-cigarettes,” but you should include details of use, such as type of device used and frequency of use. This is easily accomplished in a setting using paper chart- ing, but it may be challenging if using an electronic medical record (EMR), because many systems were developed before ENDS were used commonly. It may be necessary to add free-text comments in fields used to document other tobacco use. Remember to document any discussions about the known risks of ENDS use and any education provided on cessation. Example 6.1

Application Exercise 6.1 Calculate the pack-year history for a patient who has smoked two PPD for 20 years: _________ Calculate the pack-year history for a patient who has smoked one-half PPD for 15 years: _________

Application Exercise 6.1 Answer Pack-year history for a patient who has smoked two PPD for 20 years: 40 Pack-year history for a patient who has smoked one-half PPD for 15 years: 7.5

Alcohol Use Alcohol consumption is associated with a number of physical and social problems, including reduced physical coordination, reduced mental alertness, poor decision-making, double vision, and mood swings. Long-term chronic consumption of high levels of alcohol leads to higher risk for heart disease, liver dis- ease, circulatory problems, peptic ulcers, various forms of cancer, and irreversible brain damage. Screening for alcohol use should be a part of every preventive care visit. Document the type of alcohol, amount, and frequency of consumption. If the amount or frequency of alcohol use is a concern, screen for abuse or dependence. This can be accomplished through administration of the CAGE questionnaire, which was developed by Dr. John Ewing, founding director of the Bowles Center for Alcohol Studies, University of North Carolina at Chapel Hill. CAGE is an assessment instrument used internationally for identifying alcohol dependency and takes less than

1 minute to administer. CAGE is an acronym formed from the boldfaced letters in the questionnaire:

C. Have you ever felt the need to Cut down on drinking?

A. Have people Annoyed you by criticizing your drinking?

G. Have you ever felt Guilty about drinking? E. Have you ever taken a drink first thing in the

morning (Eye-opener) to steady your nerves or get rid of a hangover?

Patients who answer affirmatively to two questions are seven times more likely to be alcohol dependent than the general population. Those who answer negatively to all four questions are one-seventh as likely to develop alcohol dependence as the general population.

The sensitivity of the CAGE questionnaire was thought to be 75%. More recent studies, however, show that the sensitivity is lower, particularly in populations

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Chapter 6 Adult Preventive Care Visits | 131

Identification Test (AUDIT), which was developed by the World Health Organization. It is accurate 94% of the time and is also accurate across ethnic and gender groups. Furthermore, it has a greater sensitivity in populations with a lower prevalence of alcoholism than the CAGE screening tool. The test consists of 10 multiple-choice questions that are scored on a point system. AUDIT can be administered as a paper-and-pencil test. The disadvantage of the AUDIT test is that it takes longer to administer and is more difficult to score than the shorter tests. The questions and scoring guide are shown in Figure 6-3. A score of eight or more indicates an alcohol problem.

Documentation is as simple as stating the screening tool used and the score, such as “CAGE score = 4” or “AUDIT score of 9.”

Use of Other Substances Hazardous substance use, abuse, and dependence are more prevalent in the United States than some of the conditions that are routinely screened for, yet health-care providers sometimes fail to identify patients with sub- stance abuse issues. One tool that screens for substance abuse is the Drug Abuse Screening Test (DAST-10) developed by Harvey Skinner, PhD. It is a 10-item, yes/no, self-report instrument that asks questions about involvement with drugs in the past 12 months and should take less than 8 minutes to complete. The DAST-10 is intended for use with patients 18 years of age and older. In this screening tool, “drug abuse” refers to the use of prescribed or over-the-counter drugs in excess of the directions and any nonmedical use of drugs. The tool and scoring guidelines are shown in Figure 6-4.

Another tool used for substance abuse screening is the National Institute on Drug Abuse Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA Modified ASSIST). The screening may be administered in a written version or even accessed online. If using a written version, provide a blank cover page to protect patient confidentiality, and then place the completed questionnaire in the patient’s medical record. The NIDA Modified ASSIST may be used to screen for tobacco, alcohol, and substance use and dependence. The first question asks, “Which of the following substances have you used in your lifetime?” (a) tobacco products, (b) alcoholic beverages, (c) cannabis, (d) cocaine, (e) pre- scription stimulants, (f ) methamphetamine, (g) inhalants, (h) sedatives or sleeping pills, (i) hallucinogens, (j) street opioids, (k) prescription opioids, (l) other. If the answer is “none,” then the screening is complete. If the patient answers affirmatively to using any of the substances, then the next question asks if the patient has used the substance(s) in the past 3 months. Other questions ask how often the patient has a strong desire or urge to use; how often use of the substance has led to health,

with a lower prevalence of alcohol use, such as women and older adults. The CAGE test is designed to test alcohol dependency over a lifetime but may fail to identify binge drinkers.

The FAST test consists of four questions designed to measure a person’s hazardous drinking in the past year; answers are never, less than monthly, monthly, weekly, daily or almost daily. The first question is “How often do you have eight or more drinks on one occasion?” If a person answers “never,” then he or she is not a haz- ardous drinker, and the remaining questions are not necessary. If a person answers “monthly” or “less than monthly,” then the other three questions are needed to complete the screening. If a person answers “weekly” or “daily or almost daily” on the first question, then he or she is considered a hazardous drinker, and you can skip the rest of the questions. The remaining questions are: 1. How often during the last year have you been

unable to remember what happened the night before because you had been drinking?

2. How often during the last year have you failed to do what was normally expected of you because of your drinking?

3. Has a relative or friend, a doctor or other health worker been concerned about your drinking or suggested you cut down?

Because of the risk for fetal harm, it is particularly important to screen for alcohol use in women who are pregnant or who may become pregnant. Studies have shown that the T-ACE questionnaire, a four-item screening questionnaire based on the CAGE screen- ing tool, is considered accurate in detecting drinking problems in pregnant women.

The T-ACE questions are: T – Tolerance: How many drinks does it take to

make you feel high? A – Have people annoyed you by criticizing your

drinking? C – Have you ever felt you ought to cut down on

your drinking? E – Eye-opener: Have you ever had a drink first

thing in the morning to steady your nerves or get rid of a hangover?

Affirmative answers to questions A, C, and E are each scored one point. A reply of more than two drinks to the T question is scored two points. The T-ACE is considered to be positive with a score of two or more. You should conduct further assessment, provide education, and implement treatment for women who screen positive in order to reduce the risk of harm to the developing fetus and to maximize pregnancy outcome.

One of the most accurate tests available to screen for problem drinking is the Alcohol Use Disorders

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132 | Guide to Clinical Documentation

Figure 6-3 Alcohol Use Disorders Identification Test (AUDIT). A score of 8 or more on the AUDIT generally indicates harmful or hazardous drinking. The first eight questions are scored 0, 1, 2, 3, or 4 points. The last two questions are scored 0, 2, or 4 only. (From Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care. 2nd ed. Geneva, Switzerland: World Health Organization, Department of Mental Health and Substance Dependence; 2001.)

Questions

How often do you have a drink containing alcohol?

How many drinks containing alcohol do you have on a typical day when you are drinking?

How often do you have 6 or more drinks on one occasion?

How often during the past year have you found that you were not able to stop drinking once you started?

How often during the past year have you failed to do what was normally expected of you because of drinking?

How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session?

How often during the past year have you had feelings of guilt or remorse after drinking?

How often during the past year have you been unable to remember what happened the night before because you had been drinking?

Have you or has someone else been injured as a result of your drinking?

Has a relative, friend, doctor, or health-care worker been concerned about your drinking or suggested you cut down?

0 Points

Never

1 or 2

1 Point

Monthly or less

3 or 4

Less than monthly

2 Points

2–4 times a month

5 or 6

Monthly

Yes, but not in the past year

3 Points

2–3 times per week

7–9

2–3 times per week

4 Points

4 or more times a week

10 or more

4 or more times a week

Yes, during the past year

Never

Less than monthly

Yes, but not in the past year

Yes, during the past year

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social, legal, or financial problems; and how often use of the substance has caused the patient to fail to do what was normally expected of him or her. Answers include never, once or twice, monthly, weekly, or daily or almost daily. Three yes/no questions complete the screening: 1. Has a friend or relative ever expressed concern

about your use of the drug? 2. Have you ever tried and failed to control, cut

down, or stop using the drug? 3. Have you ever used the drug by injection?

If the answer to the last question is yes, you should ask about the pattern of injecting and recommend testing for HIV and hepatitis B and C. For complete informa- tion on administering and scoring the NIDA Modified ASSIST screen, please visit the National Institute on Drug Abuse website at www.drugabuse.gov.

Sexual History Patients and health-care providers alike may not be comfortable talking about the patient’s sexual history,

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Figure 6-4 Drug Abuse Screening Test (DAST-10). (Courtesy of Dr. Harvey A. Skinner, Dean, Faculty of Health, York University, Toronto, Canada.)

The following questions concern information about your possible involvement with drugs (not including alcoholic beverages) during the past 12 months. Carefully read each statement and decide if your answer is “Yes” or “No.” Then check the appropriate response beside the question.

In the following statements “drug abuse” refers to: 1. The use of prescribed or over-the-counter drugs in excess of the directions, and 2. Any nonmedical use of drugs.

The various classes of drugs may include cannabis (marijuana, hashish), solvents (e.g., paint thinner), tranquilizers (e.g., Valium), barbiturates, cocaine, stimulants (e.g., speed), hallucinogens (e.g., LSD), or narcotics (e.g., heroin).

1. Have you used drugs other than those required for medical reasons? Yes No

2. Do you abuse more than one drug at a time? Yes No

3. Are you unable to stop using drugs when you want to? Yes No

4. Have you ever had blackouts or flashbacks as a result of drug use? Yes No

5. Do you ever feel bad or guilty about your drug use? Yes No

6. Does your spouse (or parents or friends) ever complain about your involvement with drugs? Yes No

7. Have you neglected your family because of your use of drugs? Yes No

8. Have you engaged in illegal activities in order to obtain drugs? Yes No

9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped using drugs? Yes No

10. Have you had medical problems as a result of your drug use (e.g., memory loss, hepatitis, Yes No convulsions, bleeding)?

One point is given for each “Yes” answer.

Score Degree of Probability Related to Drug Abuse Suggested Action

0 No problems None at this time 1–2 Low level Monitor; reassess at later date 3–5 Moderate level Further investigation required 6–8 Substantial level Assessment required 9–10 Severe level Assessment required

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sex partners, or sexual practices, but it is important to emphasize to patients that taking a sexual history is a necessary part of a regular medical history. A sexual history allows you to identify individuals at risk for sexually transmitted diseases (STDs; also, sexually transmitted infections, or STIs), such as syphilis, human papillomavirus (HPV), HIV, pelvic inflammatory disease (PID), and hepatitis, and helps to identify appropriate anatomical sites for certain STD tests. As with all parts of the history, you may need to modify the sexual history to be appropriate for some patients based on culture or gender dynamics.

The contents of a sexual history that should be documented can be remembered by the five Ps:

• Partners • Practices • Protection from STDs

• Past history of STDs • Prevention of pregnancy

Appendix B provides a list of specific questions that you can ask to obtain the history in each of the five areas. Then you can tailor appropriate screening measures to the patient based on risk factors identified by the sexual history.

Intimate Partner Violence (IPV) Sometimes referred to as domestic violence, family vio- lence, or relationship violence, intimate partner violence (IPV) refers to violence occurring between people who are, or were formerly, in an intimate relationship. IPV can occur on a continuum from economic, psychological, and emotional abuse to physical and sexual violence. Although men are among the victims of IPV, evidence suggests that most victims are women and that women

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Some of the specific exposures that OSHA monitors can be grouped as follows:

• Mechanical: equipment-related injury, puncture wounds, falls/slips/trips, impact force, compressed air, high-pressure fluid injection

• Physical: noise, ionizing radiation, heat or cold stress, electricity, dehydration

• Biological: bacteria, fungi (mold), virus, tuberculo- sis, blood-borne pathogens (e.g., hepatitis, HIV)

• Chemical: acids, bases, heavy metals (e.g., lead), solvents (e.g., petroleum), particulates (e.g., asbes- tos), fumes (e.g., noxious gases, vapors), fire

• Psychosocial: work-related stress (e.g., too much overtime), harassment (e.g., sexual, verbal, emo- tional), burnout

• Musculoskeletal: carpal tunnel syndrome (CTS) and back pain, which account for one third of all serious injuries suffered by American workers

Determine the patient’s specific job duties and assess risk for work-related injury or any possible exposures. If an individual is exposed to potential hazards, ask whether the employer provides screening. Document the type of screening and how often the screening is done. Document the use of personal protective devices, such as goggles, and hearing protection.

Oral Health According to the Centers for Disease Control and Prevention (CDC), nearly one third of adults in the United States have untreated tooth decay and 42% of adults 30 years of age and older have some form of periodontal disease; this increases to 70% in adults 65 years of age and older. In addition, nearly one fourth of all adults have experienced some facial pain in the past 6 months. Oral cancers are most common in older adults, particularly those older than 55 years of age who smoke and are heavy drinkers. Unfortunately, many adults do not get regular dental care. Documentation related to oral health should include the number of dental caries, identification of missing or broken teeth, condition of the patient’s gums, and the patient’s personal oral hygiene habits, such as the frequency of brushing and flossing and use of fluoride toothpaste.

Blood or Blood Product Transfusions Although blood or blood product transfusions are rarely administered in an ambulatory care setting, there are health risks associated with having had transfusions and so any past transfusions should be documented in the patient’s record. Document the date, type of product transfused (e.g., whole blood, packed cells, fresh-frozen plasma), number of units transfused, and the reason. Document whether there were any complications from the transfusion.

are more vulnerable to its health impacts. Conduct IPV screening by asking three simple questions:

1. Within the past year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?

2. Are you in a relationship with a person who threatens or physically hurts you?

3. Has anyone forced you to participate in sexual activities that made you feel uncomfortable?

With your patient’s disclosure of IPV, your respon- sibilities include acknowledging the abuse, making a safety assessment, assisting with a safety plan, providing appropriate referrals, and documenting. Documentation should specifically include the victim’s description of current and past abuse, the name of the alleged perpetra- tor and relationship to the victim, and any information or referrals that you provide to the victim. You should document a detailed description of all physical injuries, including the type of injury, location (in relation to fixed landmarks or standard anatomical regions), length, width, shape, color, depth, degree of healing, and other relevant details such as swelling. Include a detailed description of the patient’s psychological demeanor, noting gestures, facial expressions, and other relevant aspects. Use a body diagram to document the location of all visible injuries and scars. If the patient consents, photographs may be included in the documentation and should be identified by the patient’s name, date the photograph was taken, identity of the person taking the photograph, and setting in which the photograph was taken.

Safety Measures Adults are at risk for injury resulting from motor vehi- cle crashes; therefore, safety screening should include documentation of seat belt use and risky behavior while driving, such as drinking alcohol and use of cell phones. If the patient rides a motorcycle or bicycle, inquire about helmet use. Consider safety in the home as well; ask the patient about and document the presence of weapons or firearms, smoke detectors, and any safety equipment such as grab bars in a tub or shower area. If the patient has a pool, document the presence of a fence around the pool and a pool alarm. In instances of water recreation or sports, document the patient’s use of sunscreen, personal flotation devices, and eye protection.

Occupational History The U.S. Congress created the Occupational Safety and Health Administration (OSHA) in 1970. Its mission is to prevent work-related injuries, illnesses, and occupational fatalities by issuing and enforcing standards for workplace safety and health. OSHA’s role is to ensure safe and healthful working conditions.

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or disease screening for populations identified as high risk. If the patient’s history is positive for any of these familial-tendency conditions, it is important to educate the patient that he or she has these nonmodifiable risk factors. The more nonmodifiable risk factors a patient has, the more important it is that the patient reduce risk by controlling those risk factors that can be modified. Documentation should reflect the education provided initially, and you should document any progress toward risk modification at subsequent visits.

Assessing family history as part of risk stratification is a key initiative of the CDC and HHS. The CDC tool is Family Healthware, an interactive, Web-based tool that assesses familial risk for six diseases (coronary heart disease; stroke; diabetes; and colorectal, breast, and ovarian cancer) and provides a “prevention plan” with personalized recommendations for lifestyle changes and screening. This tool can be accessed at www.fam- ilyhealthware.com/consumer. If a patient completes the screening and is found to have risk for any of the diseases, document which disease(s) and the prevention plan that is implemented.

“My Family Health Portrait” was developed by HHS through the Office of the Surgeon General. Part of this initiative is to encourage discussion among family mem- bers about their health history. The tool helps patients assemble and organize family history information and makes a pedigree, which then the patient can print and present to his or her health-care provider. It does not offer medical advice or screening recommendations. The tool is accessible at https://familyhistory.hhs.gov. If the patient brings in a printed report, you should incorporate it into the medical record. You should discuss the results with the patient, and you should document if any action is indicated, such as additional screening.

Risk Factor Identification Based on Screening Tests The U.S. Preventive Services Task Force (USPSTF) is mandated by Congress to conduct rigorous reviews of scientific evidence to create evidence-based recommen- dations for preventive services that may be provided in the primary care setting. Since its inception, the USPSTF has made and maintained recommendations on dozens of clinical preventive services that are in- tended to prevent or reduce the risk for heart disease, cancer, infectious diseases, and other conditions and events that impact the health of children, adolescents, adults, and pregnant women. The task force assigns each recommendation a letter grade, as shown in Table 6-1, based on the strength of the evidence and the balance of benefits and harms of a preventive service. The task force does not consider the costs of a preventive ser- vice when determining a recommendation grade. The recommendations apply only to people who have no

Risk Factor Identification Based on Family History Obtaining a detailed family history enables you to assess risk due to the complex interactions of genes, lifestyle, and exposures experienced by family members as well as susceptibility due to single genes. Conditions known to have a genetic familial tendency include diabetes, cardiovascular disease, hypertension, hyperlipidemia, certain types of cancer, asthma, and osteoporosis. Establishing genetic risk factors may enable an ear- lier or more accurate diagnosis and allows you and your patient to determine the degree of intervention needed, such as preventive measures, surveillance, or management. It is common practice to inquire about the medical history of parents, siblings, and grandpar- ents; however, there are several hereditary conditions that require information about multiple generations to understand various inheritance patterns, such as with certain cancers. At a minimum, documentation of the family history should include the age, health status, and presence of diseases of first-degree relatives, defined as parents, grandparents, and siblings. Document the age of the relative, presence of any conditions that have a genetic or familial tendency, and current health status of the individual. You should document age and cause of death for deceased relatives. It may be necessary to remind the patient that a family history is only pertinent for blood relatives, not spouses, in-laws, or people who are adopted. When a person who is adopted is unaware of his or her family history, this should be documented to alert the health-care team that the patient may be at risk for any genetic conditions. If the family history is positive for any genetically transmitted traits or con- ditions, documentation may include a pedigree chart, using standard symbols to depict inheritance patterns.

There are certain findings from the family history that are particularly important to document. These include early age at onset, two or more first-degree relatives with the same disorder or related conditions, a family member with two or more related conditions, disease occurring in the sex affected less often, and conditions that are refractory to usual treatment or prevention strategies. These are considered “red flags” in the family history and indicate a higher level of risk for family members. Algorithms have been created for certain diseases, such as coronary artery disease (CAD) and CVA, which consider these characteristics and stratify family history into three risk categories (weak, moderate, and strong). Recent literature is filled with studies evaluating statistical models that predict risk for disease or some other adverse event. The purpose of a risk prediction model is to stratify individuals accurately into risk categories that are clinically rele- vant. This risk information can be used to guide clinical decision-making about preventive interventions for people

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to as a well-woman examination (WWE), the visit includes focus on the gynecological history (including sexual history and IPV screening, as discussed earlier) for women of childbearing age as well as education about menopause and postmenopausal health concerns when appropriate. In addition to a standard physical examination, a clinical breast examination and pelvic examination should be performed. Other screening examinations, such as those shown in Table 6-3, may be clinically indicated. Your documentation should reflect what screening is done. If a recommended screening is not performed, document the rationale.

Screening for STDs and gynecological cancers is part of the pelvic examination. Obtain a Papanicolaou (Pap) test to screen for cervical cancer. Bimanual pelvic examination should be performed to assess the uterus and search for any adnexal masses. It is important to document whether there is any difficulty performing any part of the pelvic examination. Certain patient characteristics may lead to a clinically unsatisfactory examination. Rather than simply omitting the part of the examination that was difficult or unsatisfactory, you should document the difficulties encountered and describe why the examination was unsatisfactory. If a patient refuses any part of the examination or refuses to have a screening test that is indicated, you should document the patient’s refusal in the appropriate sys- tem (i.e., if the patient refuses the rectal examination, document in the genitourinary system) or in the plan if a recommended test is refused. Your documentation should record the findings of all screening tests and that you discussed the results with the patient.

signs or symptoms of the specific disease or condition under evaluation, and the recommendations address only services offered in the primary care setting or services referred by a primary care clinician. The most up-to-date version of the recommendations, as well as the complete USPSTF recommendation statements, are available along with their supporting scientific evidence at www.USPreventiveServicesTaskForce.org. Some of the USPSTF recommended screening tests that are appropriate for the general adult population are shown in Table 6-2.

Various specialty societies, such as the ACS and the AHA, and government agencies, such as the CDC, also publish recommendations for screening tests. Insurance companies may have their own recommended screening tests. Many EMR systems will alert health-care providers when an age-related recommended screening test is due and may help track results of screening tests. It is beyond the scope of this book to discuss all the screening tests that could be performed; determining which screening tests to order is based on conditions and diseases for which the patient is at risk as revealed by the personal medical and social history and family history.

Gender-Specific Screening Screening for Women In addition to the history and physical examination that you will perform for all adult well visits and the screen- ing recommendations outlined in Table 6-2, the female preventive care visit typically includes additional risk assessments, screening, and counseling. Often referred

Grade Definition Suggestions for Practice A The USPSTF recommends the service. There is high

certainty that the net benefit is substantial. Offer or provide this service.

B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Offer or provide this service for selected patients depending on individual circumstances.

D The USPSTF recommends against this service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

Read the clinical considerations section of the USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

Table 6-1 USPSTF Grade Recommendations

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Condition Screening Recommendation Blood pressure Adults aged 18 years or older ; the USPSTF recommends obtaining measurements outside of the

clinical setting for diagnostic confirmation before starting treatment Breast cancer Screening mammography for women, with or without clinical breast examination, every 1 to 2 years

for women age 40 years and older Cervical cancer Women ages 21 to 65 years with cytology (Pap smear) every 3 years or, for women ages 30 to

65 years who want to lengthen the screening interval, screening with a combination of cytology and HPV testing every 5 years

Colorectal cancer Starting at age 50 years and continuing until age 75 years Diabetes As part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese Hepatitis C One-time testing for persons born from 1945 through 1965 and unaware of their infection status HIV Ages 15 to 65 years; younger adolescents and older adults who are at increased risk should also be

screened Tuberculosis Those who were born in, or lived in, foreign countries where TB is common; people who live in a

large group setting; health-care workers, and those who are immunocompromised

Table 6-2 USPSTF Screening Recommendations for Common Conditions

Assessments, Screenings, and Counseling Recommendations* BRCA risk assessment and genetic counseling/

testing Risk assessments for women with a family history of breast, ovarian,

tubal, or peritoneal cancer. Women who test positive should receive genetic counseling and, if indicated after counseling, BRCA testing

Breast cancer screening (mammogram) Once every 2 years for women ages 50–74. Begin at age 30 for those at high risk or at health-care provider’s discretion

Pap and HPV test (cervical cancer screening) Pap test once every 3 years for women 21–61 years old or a Pap test with an HPV test every 5 years for women ages 30–65

IPV screening and counseling Annually HIV screening and counseling Adults up to age 65 Osteoporosis screening Women 65 and older; younger women who are at high risk Contraceptive counseling and contraception

methods FDA-approved contraceptive methods, sterilization procedures,

education, and counseling STD risk assessment, screening, and counseling Annual screening and counseling for chlamydia, gonorrhea, and syphilis

for women who are at high risk Well-woman examination One visit every 1–3 years

*Compiled from Agency for Healthcare Research and Quality (AHRQ), USPSTF, CDC, and ACOG guidelines.

Table 6-3 Screening Recommendations for Women

Preconception Care Given that nearly one half of pregnancies are unintended, preconception care should be considered an integral part of primary care for women of reproductive age. Common issues in preconception care include family planning, nutrition, achieving a healthy body weight, screening and treatment for infectious diseases, assessing immunization status and vaccinating when indicated, and reviewing medications for teratogenic effects. Control of chronic diseases is essential for optimizing pregnancy outcomes.

You should consider asking all women of reproduc- tive age about their intention to become pregnant, and then provide contraceptive counseling tailored to each patient’s intentions. The CDC’s criteria for contraceptive use can assist in counseling patients about contracep- tive choices, and it provides evidence-based guidance on the safety of contraceptive methods for women

with specific characteristics and medical conditions. Your documentation should include the options for contraception that were discussed, risks and benefits of each option, any specific monitoring needed for any particular option, and which option the patient chose. You should encourage both women and men to develop a reproductive life plan, including individual goals about childbearing and a plan for achieving them. Reproductive life planning tools are available at www .cdc.gov/preconception/reproductiveplan.html.

A patient’s weight and BMI should be recorded at every visit, but it is especially important to document for those patients who are considering or planning to become pregnant. All women with BMI below 19.8 kg/m2 or above 26 kg/m2 should be counseled about the short- and long-term risks to their own health and the risks to future pregnancies, including infertility. Women who

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inguinal hernia check as well as the general physical examination. In patients 18 to 30 years of age, perform a testicular examination to screen for testicular cancers. A prostate and rectal examination should be performed, as indicated in Table 6-4. Test the stool for occult blood as part of screening for colorectal cancer. Guidelines for prostate-specific antigen (PSA) as a screening for prostate cancer are controversial. In 2013, the American Urological Association (AUA) announced updated guidelines indicating that screening in men below 40 years of age is not indicated. Routine screening in men between 40 and 54 years of age at average risk is not recommended. For men from 55 to 69 years of age, the decision to undergo PSA screening involves weighing the benefits of preventing prostate cancer mortality in one man for every 1,000 men screened over a decade against the known potential harms associated with screening and treatment. For this reason, shared decision-making is recommended for men 55 to 69 years of age who are considering PSA screening and proceeding based on patients’ values and preferences. Routine PSA screening is not recommended in men over 70 years of age or for any man with less than a 10-year life expectancy. Your documentation should indicate which guidelines you followed as well as any discussion about PSA screening and shared decision-making that you had with the patient.

If the patient refuses to allow any part of the exam- ination, document the refusal as well as any education provided to the patient on the importance of the

are underweight have higher risks of preterm birth (less than 37 weeks estimated gestational age [EGA]), low- weight birth (less than 2,500 g), and intrauterine growth retardation. Women who are overweight or obese are at risk of diabetes, gestational diabetes, hypertension, fetal malformation, fetal macrosomia, increased cesarean delivery rate, and intrapartum and operative complica- tions. Documentation should reflect that you educated any patients who are under- or overweight on the ideal body weight as well as risks associated with their weight.

Control of chronic disease is one of the most import- ant aspects of preconception care. For any patient who indicates a desire to become pregnant, you should screen for diabetes, hypertension, seizure disorder, and use of any medication that may have teratogenic effects. It is beyond the scope of this book to address control of these diseases, but your documentation should reflect that you educated the patient on the importance of controlling these conditions. Screen patients who wish to become pregnant for STIs and other communicable diseases as indicated. Update vaccines as needed. As discussed previously, screening for use or abuse of tobacco, alcohol, and other substances as well as IPV should be part of the preventive care visits for every patient of reproductive age. Documentation should reflect what screening is done, any problems or concerns identified, and a plan to address each.

Screening for Men The male preventive health visit, also called the well-man examination, should include a genital examination and

Assessments, Screenings, and Counseling Recommendations* Abdominal aortic aneurysm Screen once with ultrasonography in men 65 to 75 years of age if they have a

family history or have smoked at least 100 cigarettes in their lifetime Cardiovascular disease risk assessment 35 years and older, and in younger men with cardiovascular risk factors; assess

blood pressure, BMI, lipid disorders Obesity screening and counseling Screen all men for obesity, and offer intensive counseling and behavioral

interventions to promote sustained weight loss Diabetes risk assessment Screen every 3 years beginning at age 45 with fasting blood sugar, HbA1C test,

or 2-hour oral glucose tolerance test. Screen more often and beginning at a younger age for those who have risk factors

Colorectal cancer screening FOBT, flexible sigmoidoscopy, or colonoscopy beginning at age 50 and continuing until age 75; may start at younger age if family history of colon cancer

Prostate cancer screening and counseling

Discuss the risks and benefits of screening with DRE and PSA beginning at age 55; initiate screening at 45 years of age in black men and in those with a first- degree relative who was diagnosed with prostate cancer before 65 years of age; continue until life expectancy is less than 10 years

STD risk assessment, screening, and counseling

Inconsistent use of condoms, new or multiple sex partners, history of and/or current STI, current partner has other sexual partner(s), men engaging in sex with other men, and immunocompromised patients through age 26, if not previously vaccinated

Well-man examination 1 visit every 1–3 years

*Compiled from AHRQ, USPSTF, CDC, ACS, and AUA guidelines.

Table 6-4 Screening Recommendations for Men

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customized to a particular practice setting or specialty. When handouts are given, document the content, and then ask follow-up questions at the next visit and de- termine whether the patient has any related questions.

Assessing Vaccination Status Review of vaccination status is an important component of the adult health maintenance visit. Vaccines are used to prevent disease, and there are several that should be maintained through adulthood. Many patients are not aware of the need for vaccines unless they are required for certain activities, occupations, or college entrance. If the patient was fully vaccinated during childhood, then vaccines that they are likely to need as adults include diphtheria-tetanus, hepatitis B, herpes zoster, HPV, varicella, influenza, and pneumonia. If the patient was not fully vaccinated during childhood, a catch-up schedule is available. The CDC is the best source for up-to-date information on adult vaccinations, schedules, and the medical indications for specific immunizations, and that information may be accessed at www.cdc.gov.

Summary Adult preventive care visits provide an opportunity to assess risk for acquiring certain medical conditions. Documentation of identified risk factors from personal history, family history, and lifestyle choices is a key component of the visit. Many tools are available to assist you with screening and assessing risk factors. Alerts in an EMR system can prompt you to complete screening tests and to track the results. Guidelines published by governmental or specialty organizations also can help you determine which diagnostic screening tests should be done and at what ages the screening should take place. Although differences in the guidelines exist, the intent of the guidelines is to encourage discussion and shared decision-making between you and each of your individual patients. Every visit is an opportunity to as- sess vaccination status and to provide health education and counseling. Detailed documentation of what was discussed is an essential part of the adult preventive care visit. To reinforce the content of this chapter, please complete the worksheets that follow. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

examination component that was refused. Your docu- mentation should record the findings of all screening tests and that you discussed the results with the patient.

MEDICOLEGAL ALERT !

If any part of the examination is deferred, document the reason so that readers of the medical records will not have to speculate. Deferral implies that the examination is not done at this time for a specific reason. “Deferral” should not be documented if the patient is actually refusing a recommended examination or test. If the patient refuses, educate the patient on the importance of performing the examination or test; if the patient persists in refusing, you should respect his or her right to refuse, but document any education provided and the risks associated with refusing the examination or test.

Health Education and Counseling According to the latest National Ambulatory Medical Care Survey (2013), health education and counseling were documented as being ordered or provided at 37.2% of office visits. The most frequent education or counseling provided was related to diet or nutrition and exercise. The preventive health visit is a convenient time to educate and counsel patients. Any patient education or counseling should be specifically documented. It is important to reinforce and praise patients for positive health behaviors and equally important to educate patients about the risks associated with negative health behaviors, such as tobacco use or sedentary lifestyle. Studies have shown that the health-care provider’s advice can have a strong influence on patient behavior. Patients may not be ready to change their behavior at any particular visit, but they may move closer to making a change when the information is reinforced over multiple visits.

It is highly recommended that you provide educa- tional information in writing when possible. This not only serves to reinforce information that was given verbally but also gives patients information that they can read at their own pace and at a time that is conve- nient for them. Many professional organizations offer patient handouts on common conditions. Resources are available in print and electronically, and many can be

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Worksheet 6.1

Name

Review

1. List the five components of the adult preventive care visit.

2. List at least five risk factors that should be screened for in the personal history.

3. List at least three diseases that are related to tobacco use.

4. List the four questions that make up the CAGE questionnaire.

5. List one advantage of the AUDIT screening tool compared with the CAGE questionnaire.

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6. List at least five substances that are screened for with the NIDA Modified ASSIST.

7. List the five Ps of the sexual history.

8. List three questions that are used to screen for IPV.

9. List at least four facts that should be documented when a patient discloses IPV.

10. List at least three potential complications associated with blood transfusion.

11. List at least four conditions that have a genetic predisposition that should be screened for when taking a

patient’s family medical history.

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12. List at least five topics that should be discussed as part of preconception care.

13. List at least three chronic medical conditions that need special attention during preconception visits.

14. G. A. is a 52-year-old man who presents for his annual well-man examination. List two specific physical

examination components and at least three screening tests that could be ordered for this patient based on

USPSTF recommendations.

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Worksheet 6.2

Name

Sexual History J. E., a 23-year-old woman, comes in for her annual WWE. Read the sexual history documented for this visit, and then answer the questions that follow. In the past 2 months, J. E. has had 3 partners. In the past year, she has had approximately 9 or 10 partners. She denies anal intercourse. Does engage in oral sex. She had been treated for an STD once in the past. She is on Seasonique oral contraceptive.

1. What additional information should have been included in J. E.’s sexual history?

2. What counseling or education would you provide to J. E. during this visit?

3. What physical examination should be done during this visit?

4. List at least three screening assessments, tests, or counseling (including those recommended by the

USPSTF) that should be done during this visit.

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Worksheet 6.3

Name

Family History Screening K.S. is a 42-year-old man who is new to your practice. He has a personal history of hypertension and dyslipidemia. After reading the results of his family history screening, answer the questions that follow.

Father: 77 years old, alive, fairly good health. Has rheumatoid arthritis, HTN, high cholesterol, and BPH.

Mother: 72 years old. Treated for colon cancer at age 56. Fair health at present.

Brother: 45 years old. Diagnosed with colon cancer 4 years ago. Had surgery.

Sister : 39 years old, alive and well. No known health problems.

PGF: health history is unknown.

PGM: died of stroke at age 81.

MGF: died of complications of pneumonia at age 72.

MGM: died at age 64; unsure of cause of death.

1. Identify the red flags from this patient’s family history.

2. What conditions with a known genetic familial tendency should K.S. be screened for at this time?

3. Based on USPSTF recommendations, what additional screening should K.S. have at this time?

4. What patient counseling or education should you provide to K.S. and document in his medical record?

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Worksheet 6.4

Name

Adult Vaccinations

Consult the current adult vaccination recommendations available at the CDC website (www.cdc.gov/vaccines/

schedules/hcp/adult.html). Answer the questions that follow.

1. What vaccines are indicated for a 40-year-old man who has sex with men and who had his last tetanus

immunization 6 years ago?

2. Which three vaccines are contraindicated in pregnant women?

3. What vaccines are recommended for a 21-year-old woman who plans to start nursing school in 6 months

who received one HPV vaccine at age 12?

4. What vaccines are recommended for a 63-year-old woman who volunteers at a public library and has

diabetes?

5. A 34-year-old man undergoes splenectomy following an accident in which he sustained blunt abdominal

trauma. Which vaccines are indicated for this patient?

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Worksheet 6.5

Name

Abbreviations

These abbreviations were introduced in Chapter 6. Beside each, write the meaning as indicated by the context

of this chapter.

ACS

AHRQ

AUDIT

CAD

CTS

DAST-10

EMR

FDA

HPV

NIDA-Modified ASSIST

PID

PSA

STI

WWE

AHA

AUA

BMI

CDC

CVA

EGA

ENDS

HHS

IPV

OSHA

PPD

STD

USPSTF

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153

Older Adult Preventive Care Visits LEARNING OUTCOMES

• Identify history-based risk factor assessments that should be addressed during visits with older adult patients. • Identify physical examination-based risk factor assessments that should be addressed during visits with

older adult patients. • Describe Beers criteria and documentation related to the criteria. • Define geriatric syndrome. • Identify four risk factors common to geriatric syndromes and tools to help assess for these risk factors. • Identify conditions that should be screened for in the older adult population according to U.S.

Preventive Services Task Force recommendations. • Discuss pre-operative evaluation of the older adult. • Discuss the purpose of advance directives. • Discuss the similarities and differences between hospice and palliative care.

Introduction People older than 65 years of age are frequent consumers of health-care services. It is estimated that older adult visits will comprise at least 30% of all visits in a typical primary care outpatient practice (Elsawy and Higgins, 2011). Older adults may present with any combination of nonspecific, apparently unrelated, and seemingly trivial complaints. Sometimes they have no complaint at all. Many older patients interpret their pain or dysfunction as “normal” signs of aging and it would not occur to them to seek medical attention for such complaints. They may visit a health-care provider simply to mollify a spouse or child. Alternatively, the older adult patient may have multiple comorbid conditions and multisystem disorders, and the focus of the visit is managing these conditions, leaving little time for preventive care and screening assessments. For older patients with many concerns, the use of a “rolling assessment” over several visits should be considered. The rolling assessment targets at least one domain for screening during each office visit.

Assessing Older Adult Risk Factors Through History Taking The assessment of an older adult patient incorporates all facets of a comprehensive history and physical examination

as presented in Chapter 2. The approach to the history and physical examination, however, should be specific to older adults, and many assessments will rely on both history and examination. Patient-driven assessment instruments, such as the Geriatric Health Questionnaire (developed by Gerald Jogerst, MD) shown in Figure 7-1, are often used. Asking patients to complete questionnaires and perform specific tasks not only saves time but also provides useful insight into their motivation and cognitive ability. To the extent that patients are unable to complete the assessment themselves, you can rely on traditional patient interviews that may involve input from a family member or other caregiver. You should follow up on any abnor- mal responses to screening questionnaires with further testing or interventions or more in-depth instruments as indicated. An important part of risk assessment screen- ing of older adult patients is to review the medication history. Other risk factors that are typically assessed through history taking are related to functional ability; socioenvironmental factors, such as living environment and nutrition; physical health, including sensory deficits and mobility; and mental health status.

Medication Use Review the patient’s medications at every visit. A care- ful determination should be made as to the merits of continuing each medication as well as prescribing any new medications. If any medications are discontinued, document the date and the reason why. If medications

Chapter 7

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Geriatric Health Questionnaire

Patient’s Name: ________________________________________________________________ Date: ____________________

Instructions: Please check the correct box.

1. General Health: In general, would you say your health is: Excellent Very Good Good Fair Poor

How much bodily pain have you had during the past 4 weeks? None Very Mild Mild Moderate Severe Very Severe

2. Activities of Daily Living: Are you fully independent (can do the activity yourself), need assistance from another person, or are dependent and unable to do the task at all? Check the correct box.

Activity Independent Need Assistance Dependent Walking Dressing Bathing Eating Toileting Driving Using telephone Shopping Preparing meals Housework Taking medications Managing finances

3. Geriatric Review of Systems: a. Do you have difficulty driving, watching TV, or reading because of poor eyesight? Yes No b. Can you hear normal conversation voice? Yes No

Do you use hearing aids? Yes No c. Do you have problems with your memory? Yes No d. Do you often feel sad or depressed? Yes No

e. Have you unintentionally lost weight in the last 6 months? Yes No

f. Do you have trouble with control of your bladder? Yes No Do you have trouble with control of your bowels? Yes No

g. How many falls have you had in the past year? _____________

h. Do you drink alcohol? Yes No If yes, how many drinks per week? _____________

4. Do you live with anyone? Yes No If yes, who? Spouse Child Other Relative Friend Who would help you in an emergency? ___________________ Who would help you with health-care decisions if you were not able to communicate your wishes? __________________ (Continued)

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Figure 7-1 Geriatric Health Questionnaire. (From Rakel D. Textbook of Family Medicine. 7th ed. Philadelphia, PA: Saunders; 2007.)

5. How many medicines do you take, including prescribed, over the counter, and vitamins? _____________ What is your system for taking your medications? Pill box Family help List or chart None

6. Are you sexually active? Yes No

7. Has anyone intentionally tried to harm you? Yes No

8. Have you had a shot to prevent pneumonia? Yes No

9. Please draw the face of a clock with all the numbers and the hands set to indicate 10 minutes after 11 o’clock.

Memory: 3 item recall after 1 minute (pen, dog, watch) # recalled ____________

Patient Signature: ____________________________________________________________ Date: _______________

Reviewing Physician: __________________________________________________________ Date: _______________

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are added or if dose adjustments are made, document the indication. Special consideration should be given to the possibility of drug–drug and drug–disease interactions; most electronic medical record (EMR) systems feature alerts that will notify the provider of such interactions. The Beers criteria, published by the American Geriatric Society (AGS), include lists of potentially inappropriate medication to be avoided in older adults. The 2015 update includes lists of select drugs that should be avoided or should have their doses adjusted based on an individual’s kidney function. The update also includes select drug–drug interactions that were documented to be associated with harm in older adults. Unfortunately, the criteria have sometimes been misinterpreted and misused. The potentially inappropriate medications are just that—potentially inappropriate—and should not be misconstrued as universally unacceptable for older adults in all cases. If you are prescribing a medication identified as potentially inappropriate, you should document your rationale for doing so as shown in Example 7.1.

EXAMPLE 7.1

E.P.’s urine culture showed infection with multidrug resistant E. coli. The only effective oral antibiotic is nitrofurantoin, which is identified by Beers criteria as a medication that is potentially inappropriate. All other effective antibiotics would require parenteral admin- istration. E.P.’s most recent blood work demonstrates estimated glomerular filtration rate greater than 50%, so she is not likely to have accumulation effects due to inadequate excretion. She does not have any pulmonary disease. I discussed the culture results and treatment options with E.P. and she would prefer to take oral medication rather than intravenous. A prescription was sent to her pharmacy for standard 10-day course of nitrofurantoin.

To become more familiar with the Beers criteria, complete Application Exercise 7.1.

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Katz Index. The Lawton IADL instrument is most useful for identifying how a person is functioning at the present time and for identifying improvement or deterioration over time. It measures eight domains of function. Women are scored on all eight areas of func- tion; historically, for men, the areas of food preparation, housekeeping, and laundering are excluded. Patients are scored according to their highest level of functioning in each category. Scores range from 0 to 8 for women, and 0 to 5 for men; the higher the score, the greater the person’s level of independence. Deficits in the ADL or IADL can signal the need for problem-specific physical examination, more in-depth evaluation of the patient’s circumstances, and the need for additional assistance.

Nutrition Aging is accompanied by physiological changes that can negatively affect nutritional status. Sensory impairments that occur with aging, such as decreased sense of taste and smell, may result in decreased appetite. Poor oral health and dental problems can lead to difficulty chewing, inflammation, and a monotonous diet that is poor in quality, all of which increase the risk for malnutrition. Progressive loss of vision and hearing, as well as osteoarthritis, may limit mobility and affect an older adult’s ability to shop for food and prepare meals. Energy needs decrease with age, yet the need for most nutrients remains relatively unchanged, resulting in an increased risk for malnutrition.

Nutritional assessment for older adults is accomplished by history taking, physical examination, and may include select laboratory tests if indicated. One useful screening tool for obtaining a nutritional history is the Nutritional Health Checklist, shown in Figure 7-2. Another tool is the Mini Nutritional Assessment—Short Form (MNA-SF), which provides an easy way to screen older adults for

Functional Impairment Assessment of functional impairment should be docu- mented as part of the older adult’s history, typically as part of the social history and/or the review of systems. Additional screening will be done as part of the physical examination. Functional impairment is defined as diffi- culty performing or requiring the assistance of another person to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs). You should establish a baseline of the patient’s ability to perform these tasks at about 65 years of age, but you may do it earlier if indicated by the presence of chronic disease or significant morbidities. Documentation of the type of screening done and the results of screening provides a benchmark against which to measure future levels of function and to determine the need for support services or placement (e.g., in an assisted living facility or nursing home), for medical or surgical interventions (e.g., total hip or knee replacement), or for rehabilitative services (e.g., occupational or physical therapy). Two commonly used tools to screen patients and document their functional ability are the Katz Index of ADLs and Lawton IADL Scale. The Katz Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Patients are scored yes/no for independence in each of these six functions. A score of 6 indicates full function; 4 indicates moderate impairment; and 2 or less indicates severe functional impairment. The Lawton IADL Scale is an appropriate instrument to assess independent living skills, such as the ability to use the telephone, go shopping, prepare food, do laundry, practice housekeeping, handle finances, have responsibility for one’s own medication, and provide transportation. These skills are considered more complex than the basic ADLs measured by the

Application Exercise 7.1 Access the 2015 Beers criteria and complete the following: Identify two classes of drugs that should be avoided in patients with a history of falls and identify the class of

highest strength recommendation.

Identify two drugs/classes that should be avoided in patients taking warfarin.

Application Exercise 7.1 Answer Any of the following classes of drugs should be avoided in patients with a history of falls: anticonvulsants, antipsychotics, benzodiazepines; tricyclic antidepressants, selective serotonin reuptake inhibitors; opioids.

The class of highest strength recommendation: anticonvulsants.

Drugs/classes that should be avoided in patients taking warfarin: amiodarone; nonsteroidal anti-inflammatory drugs.

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The Nutrition Screening Initiative • 1010 Wisconsin Avenue, NW • Suite 800 • Washington, DC 20007 The Nutrition Screening Initiative is funded in part by a grant from Ross Products Division of Abbott Laboratories, Inc.

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Figure 7-2 Nutritional Health Checklist. (Courtesy of The Nutrition Screening Initiative, Ross Products Division of Abbott Laboratories, Inc.)

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physical and mental health. Hearing loss inhibits the ability to interpret speech. This, in turn, may reduce a patient’s ability to communicate, which can result in social isolation, depression, and anxiety and can pose environmental safety issues, such as the inability to hear warning alarms or someone knocking on the door. The United States Preventive Services Task Force (USPSTF) currently recommends screening older adults for hearing impairment by periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making refer- rals for abnormalities when appropriate. The optimal frequency of such screening has not been determined and is left to the clinician’s discretion.

The Hearing-Dependent Daily Activities (HDDA) Scale is shown in Figure 7-3. It is a rapid and easy method of assessing the impact of hearing loss on daily life. This scale has been shown to correlate well with pure tone audiometry, which is the standard test for assessment of

malnutrition in less than 5 minutes. The form consists of six questions and has been validated as an efficient screening tool. The score for screening is derived from six components—reduced food intake in the preceding 3 months; weight loss during the preceding 3 months; mobility; psychological stress or acute disease in the preceding 3 months; neuropsychological problems; and body mass index (BMI). The MNA-SF has predictive validity for other components, including adverse health outcome, social functioning, and rate of visits to the general practitioner as well as length of hospital stay, likelihood of discharge to a nursing home, and mortality. The com- plete tool and scoring criteria may be accessed at www .mna-elderly.com. Positive findings in the history should prompt further assessment with physical examination.

Sensory Deficit Screening Hearing loss is the third most prevalent chronic condi- tion in older adults and has important effects on their

Figure 7-3 Hearing-Dependent Daily Activities (HDDA) Scale. (From the American Academy of Family Physicians. Hidalgo JL-T, et al. The Hearing-Dependent Daily Activities Scale to evaluate impact of hearing loss in older people. Ann Fam Med. 2008;6:441-447.)

The table below presents the Hearing-Dependent Daily Activities (HDDA) questionnaire used to evaluate the effect of hearing loss in older persons. Providers should score “Always” and “No, I Can’t” as 0 points, “Occasionally” and “With Some Difficulty” as 1 point, and “Never” and “Yes, Without Difficulty” as 2 points.

No. Questions

10.

11.

Have you noticed that you don’t hear as well as you used to?1.

Has anybody told you that you don’t hear well?

Does your family tell you that you turn up the volume of the television or radio very loudly?

Never

Yes, Without

Difficulty

OccasionallyAlways

With Some Difficulty

No, I Can’t

When you’re talking to someone, do you have to ask the person to speak louder?

When you’re talking to someone, do you have to ask the person to repeat what they’re saying various times?

Can you understand when someone is speaking to you in a low voice?

Can you understand when someone is speaking to you on the telephone?

Can you hear the sound of a coin dropping on the floor?

Can you hear the sound of a door closing?

Can you hear when someone approaches you from behind?

Can you hear when someone is speaking to you in a noisy setting such as a pub or restaurant?

12. Can you hold a conversation in a group setting when several people are speaking at the same time?

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history of all older adults. Four risk factors have been identified as common to these syndromes: 1. Older age 2. Functional impairment 3. Cognitive impairment 4. Impaired mobility

Three of these four factors are amenable to intervention; therefore, it is imperative that you assess your older adult patients for these risk factors. Documenting the presence or absence of these risk factors, and a treat- ment plan to address each one, should be part of every preventive care visit for the older adult.

Falls are a significant cause of morbidity and mortal- ity, occurring in 30% of adults over 65 years of age and 40% over 80 years of age; therefore, the focus should be on preventing falls. Environmental factors that can help prevent falls include adequate lighting, use of grab bars or assistive devices such as canes or walkers, a clutter-free environment, and removing throw rugs or having nonskid backs on all rugs. If there are pets in the house, patients should be alert to their location to avoid tripping over them. Nonenvironmental factors that may cause falls include decrease in vision; lack of flexibility; loss of muscle strength, especially in the legs; and changes in sleep patterns. Other important risk factors for falls in older adults are medication use and chronic health conditions. High-risk medications include calcium channel blockers, analgesics, sedatives, and hypnotics. If a patient has been prescribed any of these medications, make sure he or she is educated on the potential risk, and the education that you provide should be documented. Conditions such as heart disease, peripheral vascular disease, neuropathies, and bladder incontinence also can increase the risk for falling.

Assessing Older Adult Risk Factors Through Physical Examination The physical examination of the older adult follows the standard head-to-toe approach. Positive findings from the history will help guide the physical examination. The general assessment is important to establish an overall sense of the patient’s health status and global functioning. You should document the patient’s height, weight, and BMI at every visit, along with standard vital signs. If the patient has any chronic medical problems, such as cardiovascular disease or arthritis, you should examine the corresponding body system(s) and document your findings. Other specific screening recommendations for older adults are presented.

hearing loss. Patients are asked 12 questions about their level of hearing and understanding. Each question has a range of three possible answers. The lower the score, the greater the impact of hearing loss on the patient’s daily activities. If you identify a hearing deficit through history taking, then the physical examination should include specific measures to assess hearing.

Visual deficits can dramatically impact a person’s mobility and other essential functions, such as meal preparation or medication management. As part of the review of systems, document if there have been any changes in vision, date of last vision testing, presence or absence of eye discomfort or pain, excessive tearing, or blurred vision.

Mental Health Screening Depression is common in older adults and may go un- detected unless specifically screened for. If the patient gives a positive response to either of the following two questions, further inquiry is needed: • Over the past month, have you often been both-

ered by feeling sad, depressed, or hopeless? • During the past month, have you often been

bothered by little interest or pleasure in doing things?

The Geriatric Depression Scale (GDS) is designed specifically to screen for depression in older adults. The GDS questions are answered yes or no. This simplicity enables the scale to be used with individuals who are ill or moderately cognitively impaired. Two different scales are available: a long form that contains 30 questions and a short form that contains 15 questions. Either form may be used as part of a comprehensive geriatric assessment. The scoring for the long form, shown in Figure 7-4, sets a range of 0 to 9 as “normal,” 10 to 19 as “mildly depressed,” and 20 to 30 as “severely depressed.” The short form has a similar scale, with 0 to 4 being “normal,” 5 to 7 “mildly depressed,” 8 to 11 “moderately depressed,” and 12 to 15 “severely depressed.”

Geriatric Syndromes The term geriatric syndrome has been defined by Inouye and colleagues (2007) as “multifactorial health conditions that occur when the accumulated effects of impairments in multiple systems render an older person vulnerable to situational challenges.” The term is used to capture those clinical conditions in older people that do not fit into discrete disease categories and include conditions such as functional decline, falls, delirium, frailty, pressure injuries, and urinary incontinence. These syndromes represent common, serious conditions for older people, holding substantial implications for functioning and quality of life, and should be assessed as part of the

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Figure 7-4 Geriatric Depression Scale, long form. (From Brink TL, Yesavage JA, Lum O, Heersema P, Adey MB, Rose TL. Screening tests for geriatric depression. Clin Gerontol. 1982;1:37-44.

Geriatric Depression Scale, Long Form

1. Are you basically satisfied with your life? 2. Have you dropped many of your activities and interests? 3. Do you feel that your life is empty? 4. Do you often get bored? 5. Are you hopeful about the future? 6. Are you bothered by thoughts you can’t get out of your head? 7. Are you in good spirits most of the time? 8. Are you afraid that something bad is going to happen to you? 9. Do you feel happy most of the time? 10. Do you often feel helpless? 11. Do you often get restless and fidgety? 12. Do you prefer to stay at home, rather than going out and doing new things? 13. Do you frequently worry about the future? 14. Do you feel you have more problems with memory than most? 15. Do you think it is wonderful to be alive now? 16. Do you often feel downhearted and blue? 17. Do you feel pretty worthless the way you are now? 18. Do you worry a lot about the past? 19. Do you find life very exciting? 20. Is it hard for you to get started on new projects? 21. Do you feel full of energy? 22. Do you feel that your situation is hopeless? 23. Do you think that most people are better off than you are? 24. Do you frequently get upset over little things? 25. Do you frequently feel like crying? 26. Do you have trouble concentrating? 27. Do you enjoy getting up in the morning? 28. Do you prefer to avoid social gatherings? 29. Is it easy for you to make decisions? 30. Is your mind as clear as it used to be?

Original scoring for the scale; one point for each of these answers.

1. no 11. yes 21. no 2. yes 12. yes 22. yes 3. yes 13. yes 23. yes 4. yes 14. yes 24. yes 5. no 15. no 25. yes 6. yes 16. yes 26. yes 7. no 17. yes 27. no 8. yes 18. yes 28. yes 9. no 19. no 29. no 20. yes 30. no

Scale 0–9 Normal range 10–19 Mild depression 20–30 Severe depression

10. yes

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Sensory Examinations The prevalence of visual and auditory impairment is high in the older adult and may contribute to an individual’s inability to function independently and in a safe manner. You should check both near and distant vision and refer the patient for further evaluation if corrected vision is greater than 20/40. Document the presence or absence of cataracts as well as findings of fundoscopic examination. Regular screening for glaucoma, the second highest cause of blindness in

the United States, is recommended for all patients who are 60 years of age and older. Patients at higher risk (African Americans and those with a family history of glaucoma) should start regular screening at 40 years of age.

If the history revealed any positive findings related to hearing changes, physical examination should include otoscopic examination because cerumen impaction is a common reversible cause of hearing loss in older adults. Rinne and Weber tests may help distinguish between

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diagnostic criteria for dementia) in many people. For scoring, one point is given for each recalled word. The CDT is scored as either “normal” (patient places the correct time and the clock appears grossly normal) or “abnormal” (incorrect time or abnormal clock). A score of zero is positive for cognitive impairment. An abnormal CDT with a score of 1 or 2 on the three-word recall test is positive for cognitive impairment. A normal CDT and a score of 1 or 2 on the word recall test is negative for cognitive impairment. You should incorporate the completed CDT into the patient’s medical record, and the patient’s serial drawings over time can be helpful in determining disease progression.

Additional Screening National guidelines are established for routine screening of older adults for certain conditions. The USPSTF recommendations for older adults include screening for the following medical conditions, which is gener- ally accomplished through a combination of physical examination and laboratory and other diagnostic tests:

• Abdominal aortic aneurysm • Breast cancer • Carotid artery stenosis • Coronary artery disease • Cervical cancer • Colorectal cancer • Osteoporosis • Ovarian cancer • Peripheral artery disease • Thyroid disease

A list of all USPSTF recommendations may be found at www.uspreventiveservicestaskforce.org/Page/Name/ topics-and-recommendations.

In addition to these screening tests, you should assess the vaccination status of the older adult at every visit. The Centers for Disease Control and Prevention (CDC) regularly publishes recommended vaccination schedules for older adults; the schedule may be viewed at www. cdc.gov/vaccines. When vaccines are given, document the date of administration, vaccine manufacturer and lot number, and the name of the health-care professional who administered the vaccine.

Pre-operative Evaluation of Older Adults Although older adults are not the only ones who may need pre-operative evaluation, the percentage of peri-operative complications is higher in the older adult

conduction and sensorineural hearing loss and may prompt referral for further evaluation.

Balance and Mobility Assessment Several tools exist to help determine a person’s risk for falling. One very simple test is the Timed Up and Go test. The score is recorded as the number of seconds it took to complete the test and gives an assessment of the patient’s mobility. Another tool is the Berg Balance Test, which is a performance-based assessment tool that is used to evaluate standing balance during functional activities. The patient is scored on 14 different tasks, such as reaching, bending, transferring, and standing. Elements of the test are representative of daily activities that require balance, such as sitting, standing, leaning over, and stepping. Some tasks are rated according to the quality of the performance of the task, whereas others are evaluated by the time required to complete the task. Scores for each item range from 0 (cannot perform) to 4 (normal performance). Overall scores range from 0 (severely impaired balance) to 5 (excellent balance). The Tinetti Performance Oriented Mobility Assessment tool is a test that evaluates both balance and gait. It starts with a component to measure balance, similar to the Timed Up and Go test described earlier. In addition, the patient’s gait is evaluated for step length and height, symmetry, and continuity. Other factors, such as trunk motion and walking stance, are included in the scoring. The score indicates the patient’s risk of falling as low, medium, or high; the lower the score, the greater the risk of falling. Document the tool used and the score.

Cognitive Assessment Dementia is a chronic, progressive loss of cognitive and intellectual functions. Early screening for dementia becomes more important with the advent of newer treatment regimens. The Mini-Cog test is a 3-minute instrument to screen for cognitive impairment in older adults in the primary care setting and can easily be in- corporated into the physical examination. The Mini-Cog uses a three-item recall test for memory and a simply scored clock-drawing test (CDT). The latter serves as an “informative distractor,” helping to clarify scores when the score for memory recall is intermediate. The Mini-Cog was as effective as or better than established screening tests in both an epidemiological survey in a mainstream sample and a multiethnic, multilingual population comprising many individuals of low socio- economic status and education level. In comparative tests, the Mini-Cog was at least twice as fast as the mini-mental state examination. The Mini-Cog is less affected by patient ethnicity, language, and education and can detect a variety of different dementias. Moreover, the Mini-Cog is better at detecting only mild cognitive impairment (cognitive impairment too mild to meet

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and providing a baseline level, which can be helpful information postoperatively, particularly for surgeries with potential hemorrhagic complications. Renal and liver function studies are not routinely needed but may be indicated for patients who have a medical condi- tion or medication use that would serve as indications for these tests. Pre-operative glucose determination should be obtained because the presence of diabetes increases peri-operative risks. Coagulation studies (PT, INR, PTT) are not routinely indicated, because studies have shown that the yield is very low and that abnormal results are expected or do not significantly affect management. Coagulation studies are indicated if the patient is receiving anticoagulant therapy or has a personal or family history that suggests a bleeding disorder or has evidence of liver disease.

Cardiopulmonary assessment may reveal key features that warrant pre-operative intervention or further evaluation, including elevated blood pressure, heart murmurs, or signs of congestive heart failure or chronic obstructive pulmonary disease (COPD). An ECG should be obtained in patients older than 40 years of age or in patients with a history of previously diagnosed coronary artery disease, any previous cardiovascular procedural interventions or testing, current therapies, and any current symptoms suggestive of angina or congestive heart failure. Patients in whom cardiac stress testing was normal within the past 2 years or who have had coronary bypass surgery within the past 5 years, and are without symptoms, require no further assessment. Importantly, no pre-operative cardiovascular testing should be performed if the results will not change peri-operative management (Zambouri, 2007). It is beyond the scope of this text to address specific car- diac conditions and pre-operative risk assessment for each condition; further information may be obtained from the American College of Cardiology/American Heart Association Guideline Update for Peri-operative Cardiovascular Evaluation for Noncardiac Surgery (Eagle et al, 2014).

The major pulmonary complications in the peri- operative period are atelectasis, pneumonia, and bron- chitis. Predisposing risk factors include cough, dyspnea, smoking, a history of lung disease, obesity, and abdominal or thoracic surgery. Chest x-rays may be helpful for patients with these conditions, not only to screen for active conditions but also to establish a baseline. You should evaluate patients with cough or dyspnea to identify the underlying cause of the symptoms. Advise patients who smoke cigarettes to quit smoking for 8 weeks before surgery to allow the mucociliary transport mechanism to recover, the secretions to decrease, and the carbon monoxide levels in the blood to drop. You should treat any pulmonary infections pre-operatively. Pulmonary complications may be prevented by providing patients

population than in other age groups. The purpose of a pre-operative evaluation is not to “clear” patients for elective surgery but rather to evaluate and, if necessary, implement measures to prepare higher risk patients for surgery. Pre-operative outpatient medical evaluation can decrease the length of hospital stay as well as minimize postponed or cancelled surgeries. To effectively provide this service, you should understand the risk associated with the particular type of surgery planned and relate this risk to the patient’s underlying acute and chronic medical problems. The complete evaluation should include recommendations for evaluation and treat- ment, including prophylactic therapies to minimize the peri-operative risk. Advanced age places a patient at increased risk for surgical morbidity and mortality because of increased likelihood of underlying disease states. In one study (Ersan, 2015), the mortality rate for patients older than 70 years of age undergoing elective cholecystectomy was nearly 10 times that of younger patients. When age and severity of illness are directly compared, severity of illness is a much better predictor of outcome compared to age. Emergency operations carry a greater risk compared to elective operations in all age groups, particularly older adults. Diseases associated with an increased risk for surgical complications include respiratory and cardiac disease, malnutrition, and diabetes mellitus. Ideally you should evaluate the patient several weeks before the operation, and you should manage any chronic diseases prior to surgery. The history should include information about the condition for which the surgery is planned, any past surgical procedures, and the patient’s experi- ence with anesthesia. Document the presence of any chronic medical conditions, particularly of the heart and lungs. Make note of any medications (including over-the-counter medications). You may need to adjust drug dosages in the peri-operative period. Aspirin, non- steroidal anti-inflammatory drugs, and anticoagulation medications may need to be discontinued or have dose adjustment prior to surgery to avoid excessive bleeding.

Pre-operative laboratory and diagnostic studies once routinely included a complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis, prothrombin time (PT), international normalized ratio (INR), partial thromboplastin time (PTT), electrocar- diogram (ECG), and chest x-rays. Numerous studies have subsequently shown that most of these tests were ordered without a clear indication and that only a very small percentage of the results were unexpectedly abnormal. Current recommendations call for fewer routine tests and for selective ordering of laboratory tests based on specific indications. In addition, the availability of previous laboratory testing can obviate the need for pre-operative tests. A hemoglobin mea- surement is useful in detecting unsuspected anemia

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planned and patient-specific health parameters to deter- mine the patient’s overall risk of developing postoperative complications. A written report can be generated, which you then can incorporate into the patient’s medical record. The risk calculator may be accessed at http://riskcalculator .facs.org/RiskCalculator. To gain experience in using the calculator, complete Application Exercise 7.2.

with instructions on how to perform incentive spirom- etry and deep-breathing exercises.

The decision to proceed with elective surgery begins with an assessment of risk of developing postoperative complications. A Web-based risk calculator is available from the American College of Surgeons (ACS) that allows you to enter information about the type of surgery

Application Exercise 7.2 Access the ACS risk calculator. 1. Enter the following information for patient V. S., a 72-year-old woman who is scheduled for elective total

hip arthroplasty (code 27130). She is functionally independent, has mild systemic disease, and takes medi- cation for hypertension. Her history is negative for all remaining risk factors. She is 5 feet, 4 inches tall and weighs 156 pounds. Once all the information is entered, click on “save or print report.”

2. Enter the following information for patient P. R., an 84-year-old man who is scheduled for emergent repair of an incarcerated ventral hernia (code 49653). He is partially dependent, has severe systemic disease, and is undergoing emergent surgery. His past medical history is significant for insulin-dependent diabetes, hypertension for which he takes two medications, dyspnea with moderate exertion, and severe COPD. He is a current half-a-pack per day smoker. His history is negative for all remaining risk factors. He is 5 feet, 11 inches tall and weighs 259 pounds. Once all the information is entered, click on “save or print report.”

3. Compare the reports for these two patients. What observations do you make about each patient’s risk for postoperative complications?

Document any pre-operative advice you would give V. S.

Document any pre-operative advice you would give P. R.

Application Exercise 7.2 Answer Compare the reports for these two patients. What observations do you make about each patient’s risk for postoperative complications?

V. S.’s risk factors are age, hypertension, and being overweight. She has a 4% chance of having a serious complication and 4% chance of any complication. She has a 21% chance of discharging to skilled nursing or rehab facility.

P. R. has more risk factors, and he is at risk for several specific complications. Risk factors are age, functional status, diabetes, hypertension, the fact that he is a smoker and has dyspnea and COPD, and he is obese. He has a 12% risk for serious complication and 16% for any complication. He is at risk for pneumonia because of smoking/COPD; 2% cardiac factor because of smoking and diabetes, and 4% risk of death from all comorbidities. He has a 41% chance of discharging to skilled nursing or rehab facility.

Document any pre-operative advice you would give V.S. Lose weight if possible. Continue to control blood pressure.

Document any pre-operative advice you would give P. R.: This is an urgent procedure, so there isn’t time for any pre-operative modifications. He will need aggressive pulmonary care after surgery and he will need to be compliant with ambulation, using incentive spirometer, and all medications. Because his smoking will be interrupted during hospital stay, he is encouraged to quit smoking altogether.

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A health-care power of attorney (POA) is a document in which one person (the patient, or principal) names another person (the agent, attorney-in-fact, or proxy) to make decisions about health care. A POA differs from a living will in that it focuses on the decision-making process and not on a specific decision. The POA can cover a far broader range of health-care decisions. The health-care POA is different from a durable POA, which authorizes someone to make financial transactions for the principal; the health-care POA is specific to health-care decision-making. The health- care POA can include a living will provision, but it should do so only as guidance for the agent rather than as a binding selection. An ideal agent has the ability to talk effectively with health-care providers and act as a strong advocate. The principal should discuss the details of possible future medical choices with the agent because the agent should be guided by the principal’s preferences. The law of each state prescribes the essential formalities for a valid POA for health care. Most states require two witnesses; a few permit notarization as an alternative. Forms specific to each state are readily available from a variety of Internet sites. Once executed, a copy of the health-care POA document should be submitted to the health-care provider and made a permanent part of the patient’s medical record.

Anticipating Future Needs Advance Directives Because of aging and often having multiple chronic conditions, the older adult has increased risk of mortality. You should take advantage of outpatient visits to discuss with patients the different options for end-of-life care and to understand what their wishes are. Encourage your older adult patients to prepare advance directives, which are documents that communicate a person’s wishes about health-care decisions in the event the person becomes incapable of making such decisions. Often, patients communicate their wishes to their health-care providers, but when a person can no longer communicate sufficiently, another process for decision-making is needed. With the growing ability of medical technology to prolong life, decision-making about medical care is of great concern. Patients may have strong feelings that death is preferable to perpetual dependence on medical equipment or having no hope of returning to a certain quality of life. Others feel just as strongly that heroic measures and technology should be used to extend life as long as possible.

There are two basic kinds of advance directives: living wills and health-care power of attorney. Both have been researched and written about in detail elsewhere; only a brief discussion of each is provided here with the intention that health-care providers will talk with their patients about advance directives and encourage them to make these important decisions before being in a situation in which the directives are needed. Once the decisions are made, the patient should complete the necessary forms and submit a copy to the health-care provider so that it becomes a permanent part of the patient’s medical record.

A living will expresses a person’s preference for medical care. In some states, the document is called a directive to doctors or a declaration. Living wills become effective only when the patient has lost capacity to make health-care decisions and that patient has a particular condition, such as a terminal illness or permanent unconsciousness. Specific issues usually covered in a living will include cardiopulmonary resuscitation, mechanical ventilation, and artificial nutrition and hydration. Health-care providers often need to explain the details involved in each of these issues so that the patient can make informed decisions. To be valid, a living will must comply with state law. A living will should be signed, dated, and witnessed by two people. Some states require a notary or permit a notary in lieu of two witnesses. The executed living will should be kept as a permanent part of the patient’s medical record.

MEDICOLEGAL ALERT !

It is important to understand that a health-care POA is only in effect when a person lacks capacity to make his or her own decisions. There have been situations where a spouse or an adult child of an older adult wants to make health-care decisions for a spouse or parent who still has capacity. Sometimes, a family member or caregiver will ask a health-care provider to withhold information from a patient, for instance, not telling a pa- tient that he or she has a cancer diagnosis. If the patient still has capacity, withholding this information is inappro- priate and could provide a basis for a legal challenge, especially in the area of consent, because a patient must have adequate information to make his or her own decisions. If a health-care provider believes a patient to have capacity, the patient should be considered the decision maker. If a situation arises where a patient loses capacity and there is no health-care POA document in place and no court-appointed guardian with authority to make health-care decisions, then most states provide for a default surrogate decision maker in their state laws. Providers are responsible for knowing the laws of the state in which they practice.

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primary physician and can help with treatment of pain and other symptoms, assistance with communication regarding diagnosis and prognosis, support for patients and families in medical decision-making and in navi- gating the complex medical system, and emotional and spiritual support. Because palliative care services are often delivered through a hospital, it is likely covered by regular medical insurance.

Summary Care of the older adult presents unique challenges to health-care providers. The responsibility of managing complex and often multiple chronic diseases, along with ongoing assessment of a variety of risk factors, may seem overwhelming at times. It is helpful to use a rolling assessment approach with older adults, focusing on a single domain of risk assessment at each visit. Risk factor assessment is achieved primarily by taking an in-depth history. Positive findings from the history then direct you to areas of the physical examination that may need special attention. Many tools and references exist to aid in providing timely screening and risk assessment. Guidelines from many professional organizations are also helpful in providing risk assessment. Discussions about end-of-life care decision-making and what type of interventions a patient is willing to accept often take place with older adults and their family members or caregivers. Documentation of the patient’s wishes and intent helps to ensure that his or her wishes are honored. Reviewing the worksheets that follow will help reinforce the contents of this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

Hospice and Palliative Care Although not unique to the older patient, the need for care for noncurable or terminal conditions often arises in this population; therefore, you should understand the services that may be provided through hospice and palliative care agencies. Hospice and palliative care are very similar, and both focus on providing care and comfort to patients who are dying. Most people have heard of hospice and have a general understanding of the services provided by hospice; often, people are less familiar with palliative care. Hospice always provides palliative care, but hospice is targeted care for those patients who are no longer seeking curative therapy. For hospice services, a patient is generally considered terminal or within 6 months of death, and the referral to hospice is often through the primary care provider. Hospice programs often rely on the family caregiver, as well as a visiting hospice nurse, to provide services in the home or at an inpatient hospice facility. Most hospice services concentrate on comfort rather than aggressive disease treatment for the patient who is terminally ill. Insurance payments for hospice services vary greatly, and many hospice programs are covered under Medicare.

Palliative care often fills the gap for patients who want and need comfort at any stage of any disease, and there is usually no expectation that life-prolonging therapies or aggressive treatment will be avoided. Palliative care can be received by patients whether or not their illness is terminal, and such care focuses on providing relief from the symptoms and stress of a serious illness. The goal is to improve the patient’s quality of life. The majority of palliative care is provided in an inpatient setting. The palliative care team works in conjunction with the

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Worksheet 7.1

Name

Review

1. List at least four risk factors that should be assessed in older adults through history taking.

2. List at least four risk factors that should be assessed in older adults through the physical examination.

3. Identify the purpose of Beers criteria.

4. Define geriatric syndrome.

5. List four risk factors common to all geriatric syndromes.

6. List at least five factors that may contribute to falls in older adult patients.

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7. List at least five conditions that older adults should be screened for according to the USPSTF guidelines.

8. List two diseases associated with an increased risk for surgical complications.

9. Identify the two basic kinds of advance directives.

10. Describe the purpose of a living will.

11. Describe the difference between medical and durable power of attorney.

12. Caring Connections is a program of the National Hospice and Palliative Care Organization. Visit its website

at www.caringinfo.org and find your state’s requirements for a living will and power of attorney.

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Worksheet 7.2

Name

Older Adult Screening

J. H. is an 84-year-old man who comes in for his annual examination. He lives alone but is accompanied by his

daughter-in-law who is concerned that J. H. seems to have trouble remembering things lately. J. H. has had an

unintentional weight loss of 14 pounds since his last examination one year ago. During the examination, you

administer the Mini-Cog test. You name three items (ball, tree, chair) and have J. H. repeat them, which he does

without difficulty. You instruct him to draw a clock and to indicate 10 minutes after 8:00. His attempt at the

clock-drawing test is shown next. Later, you ask him to recall the three items; he can recall only “tree.”

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1. Based on the preceding information, how would you interpret and document J. H.’s Mini-Cog results?

2. What additional screening examinations could be conducted as part of the evaluation of J. H.’s weight

loss?

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3. Based on the USPSTF Adult Preventive Care Timeline, what other screening tests could be done at

this visit?

4. Based on his age, J. H. could be screened for other risk factors; name at least four.

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Worksheet 7.3

Name

Abbreviations

The following abbreviations were used in Chapter 7. Beside each, write the meaning as indicated by the

chapter content.

ACS

AGS

CBC

CDT

COPD

GDS

IADL

MNA-SF

USPSTF

ADL

BMI

CDC

CMP

ECG

EMR

HDDA

INR

POA

PTT

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173

Outpatient Charting and Communication LEARNING OUTCOMES

• Identify information that may be part of a patient’s medical record other than documentation of medical encounters.

• Discuss how a problem list may be used. • Discuss the rationale for maintaining a medication list. • List conditions in which flow sheets are useful. • Discuss the documentation that should be included in a noncompliance note. • Describe the typical content of a letter from a consulting provider to a referring provider. • Discuss the importance of documenting telephone communication with patients. • Discuss the use of patient portals and e-mail communication in the outpatient setting. • Discuss some of the challenges and benefits associated with health-care providers’ use of social media.

Introduction As discussed in Chapter 3, SOAP notes may be used to document the details of a patient encoun- ter in either an inpatient (hospital) or outpatient ( ambulatory care) setting. Documenting the medical encounter is just one component of a patient’s record; other types of documents should be kept to ensure continuity of care and to preserve information used in overall patient management. A medical record is created for each patient and should be arranged in a consistent, uniform manner. The contents and organization of the record will vary depending on the needs of the practice and format (paper-based or electronic). Some providers may use forms such as a problem list, medication list, or flow sheet for some of their patients. Patients may not always be compliant with recommended treatment or follow a provider’s recommendations. From a medicolegal standpoint, it is important to document noncompliance when it occurs. Other information that may become part of the patient’s medical record includes demographic and billing information, communication with other providers, results of laboratory or other diagnostic studies, immunization records, records from other

health-care providers or hospitals, information related to advance directives, and documentation of telephone and electronic communication with patients.

Components of the Medical Record Problem List To promote continuity of care by identifying key elements of the patient’s health history, information from parts of the medical records is often summarized as a problem list, such as the one shown in Figure 8-1. The list is usually prominently displayed in the chart for easy access and reference. In an electronic medical record (EMR) system, the problem list may automat- ically display when the record is opened. Problems are listed as either active or inactive. Active problems include current or chronic conditions that require ongoing management or further workup. The date of onset and the International Classification of Diseases (ICD) code for each problem is usually documented. Inactive problems are those that occurred in the past but are now resolved and can be either medical or surgical. It is important to update the list by entering

Chapter 8

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Vernon Scott, MD, PC Health History / Problem List

Name: S.S.# - - Male Adv. Directives Yes No

DOB: Tel.# - - Fem G P Ab Organ Donor Yes No

PROBLEM LIST ALLERGIES:

10.

Date: Reason: Date: Reason:

Social History Family History CANCER: colon breast other

S M D W Father: HTN: CAD: CVA:

Smoking: ETOH: Mother: DM:

Caffeine: Exercise: Siblings: Osteoporosis:

Occup: Children: Other:

Date Result

Breast

Pap/Pelvic Exam

Mammogram

Prostate/Testicular

PSA

Colonoscopy/Sigmoid

FOBT Cards

CBC

CMP

TSH

Total Cholesterol

Date Result

HDL Date Result

LDL Date Result

Triglycerides Date Result

CXR Date Result

ECG Date Result

Date ResultDEXA

Hospitalizations: Surgeries:

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Application Exercise 8.1 Use the data from Figure 8-1, create a problem list for Mr. Jensen, and then compare it with the problem list shown.

Application Exercise 8.1 Answer Problem list for Mr. Jensen.

1988

1981

right rotator cuff repair

left inguinal herniorrhaphy

Vernon Scott, MD, PC Health History / Problem List

Name: William R. Jensen S.S.# - - Male Adv. Directives Yes No

DOB: March 30, 19XX Tel.# - - Fem G P Ab Organ Donor Yes No

PROBLEM LIST ALLERGIES: PENICILLIN

1. Hypertension, diagnosed at age 53

2. Dyslipidemia, diagnosed at age 58

10. Social History Family History CANCER: colon

breast other

S M D W Father: died at age 74, complications of COPD, alcoholism HTN: X CAD: X CVA:

Smoking: pipe 3 x wk ETOH Mother: died at age 70, breast cancer DM:

Caffeine: 2–3 per day Exercise: walk Siblings: brother, age 71, HTN Osteoporosis:

Occup: retired electrician Children: Other:

Date Result

Breast

Pap/Pelvic Exam

Mammogram

Prostate/Testicular

PSA

Colonoscopy/Sigmoid

FOBT Cards

CBC

CMP

TSH

Total Cholesterol

Date Result

HDL Date Result

LDL Date Result

Triglycerides Date Result

CXR Date Result

ECG Date Result

Date ResultDEXA

Date: Reason: Date: Reason:

Hospitalizations: Surgeries:

Author Author's review (if needed)

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176 | Guide to Clinical Documentation

pertinent data as soon as they are received. For exam- ple, if a bone density report confirms the diagnosis of osteoporosis, then add this diagnosis to the problem list. Upon receiving a hospital discharge summary, any newly diagnosed conditions should be added to the list. The organization and content of the problem list will vary depending on the needs of the practice or facility.

Refer back to the comprehensive history and physical examination shown in Figure 2-2 to complete Appli- cation Exercise 8.1.

Medication List A medication list provides a quick and easy format to document all the medications a patient is taking at any given time. All prescription and nonprescription medications should be listed. It is important to include herbal products, vitamins, minerals, dietary supple- ments, or other regularly used over-the-counter (OTC) products. A comprehensive list will alert you to possible drug–drug, drug–disease, or drug–herb interactions. It also will help to avoid duplication, such as prescribing too many agents containing acetaminophen. The list should include the name of the medication, indication, strength, and dosing directions, as shown in Figure 8-2. You may wish to include the quantity written for and number of refills authorized on the medication list in order to have this information easily located in one place. (Prescription writing is covered in detail in Chapter 9.) This is helpful to office staff who may take messages from patients or pharmacies requesting refills. If a patient takes more than one prescription drug for a condition, such as antihypertensive medications, it is helpful to list those medications together. When a medication is discontinued, it is helpful to document the date and reason why directly on the medication list. Make note of any medication allergies prominently in the chart, and be sure to document on the medication list the specific reaction to each. Allergies to food or other substances, such as nickel, latex, or tape, may be included on the medication list or documented as part of the past medical history. If the patient has

had adverse reactions to any medications, such as a cough from an angiotensin-converting enzyme (ACE) inhibitor or severe nausea from codeine, document this information on the medication list as well. You may wish to include information about the patient’s insurance plan if use of a specific formulary is required. In many EMRs, formulary information is built into the system and will alert you if a medication is not covered by the patient’s insurance. It is convenient to include the name, location, and telephone number for the pharmacy that the patient uses to fill prescrip- tions; this information must be available if prescribing electronically. It is imperative that you review and update the medication list at every visit. In addition, encourage your patients to maintain their own medi- cation list because access to the record in your facility may not always be possible. Many applications are available for use on personal electronic devices, and some include reminder alerts for when medications should be taken.

MEDICOLEGAL ALERT !

Although the medication list is helpful as a quick reminder of medications that a patient is taking, you should never assume that it is a complete and accurate record. Patients may start taking medications on their own or because it was prescribed by another provider, or they may discontinue a medication and forget to tell you. It is your responsibility as the provider to determine what medications the patient is taking at every visit before writing any prescriptions. You should specifically document “medication list reviewed” and the date of the review; and if any discussion about medications ensues, document that as well.

Refer back to the comprehensive history and physical examination for Mr. William Jensen shown in Figure 2-2 to complete Application Exercise 8.2.

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Chapter 8 Outpatient Charting and Communication | 177

Figure 8-2 Sample medication list.

MEDICATION LIST

Last Name: First: Middle Initial:

Date of Birth: Contact Number:

DRUG ALLERGIES:

Preferred Pharmacy: Pharmacy Phone:

Location: Insurance Plan:

Drug Name and Dose Schedule Date Started Reason

Regular OTC Medications Dosage Frequency Reason

Supplements/Vitamins Dosage Frequency Reason

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Application Exercise 8.2 Using the blank form in Figure 8-2, complete a medication list for Mr. Jensen. Compare it with the completed form shown.

Application Exercise 8.2 Answer Medication list for Mr. Jensen.

MEDICATION LIST

Last Name: Jensen First: William Middle Initial: R.

Date of Birth: March 30, 19XX Contact Number: 555-987-6543

DRUG ALLERGIES: penicillin - rash

Preferred Pharmacy: MedMart Pharmacy Phone: 555-780-4444

Location: Poplar St at 12th Ave. Insurance Plan: Medicare

Drug Name and Dose Schedule Date Started Reason

Regular OTC Medication Dosage Frequency Reason

Supplements/Vitamins Dosage Frequency Reason

Lotensin HCT 20/12.5 every a.m. 4/10/20XX HTN

Mevacor 20 mg 1w/evening meal 10/2/20XX dyslipidemia

One-A-Day for Men 1 tablet daily general well-being

Fish oil supplement 1 tablet a.m. and p.m. CVD prophylaxis

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Chapter 8 Outpatient Charting and Communication | 179

Flow Sheets Many chronic medical conditions require regular monitoring of certain parameters. The frequency of monitoring depends on many factors, such as whether the patient is stable or unstable or if a condition is controlled or not controlled. For conditions in which monitoring of a laboratory test or some other param- eter is needed, a flow sheet is helpful. Flow sheets are commonly used to track results of coagulation studies, such as the international normalized ratio (INR) and prothrombin time (PT) for a patient on anticoagulant therapy, blood pressure readings of the patient with hypertension, blood glucose and hemoglobin A1c levels of patients with diabetes, and results of lipid studies of patients with dyslipidemia. Another use of flow sheets is to track periodic interventions or treat- ments for certain conditions, such as a patient with anemia who receives monthly vitamin B12 injections or a patient who receives Depo-Provera injections every 3 months for contraception. Figure 8-3 shows an example of a flow sheet that is used to monitor anticoagulation therapy.

Often patients are asked to track certain results at home, such as daily blood glucose monitoring or recording blood pressure measurement. Applications for use on electronic devices may assist patients with record-keeping and have the added benefit of por- tability. Some applications create graphs or tables of information that you can review with the patient. If you review results with the patient, be sure to document this, because the results are on the patient’s device and not always incorporated into the chart.

Demographic and Billing Information It is necessary to collect some demographic infor- mation about patients (Fig. 8-4). At a minimum, you should document the patient’s full legal name, address, telephone number, and date of birth. If the patient is a minor, document who is authorized to make health-care decisions for the patient. In the case of a minor when the parents are unmarried or divorced, it is prudent to document who is the custo- dial parent. Because of concerns about identity theft, it is recommended that the patient’s Social Security number (SSN) not be used as an identification number or medical record number. Include the SSN in the medical record only if it is needed for billing purposes or another specific reason.

Billing information is important to document in the record. If the patient has insurance, identify the policyholder and his or her relationship to the patient. Make a copy of the insurance identification card and keep it in the chart. It is generally recommended that

billing information and any correspondence regard- ing billing and payment issues be kept separate from clinical data.

Results of Laboratory Studies and Other Diagnostic Tests Evaluation of a patient’s condition often requires ordering laboratory tests, an electrocardiogram (ECG), imaging studies, and other diagnostic tests. Most EMR systems are designed to integrate with outside laboratories or other vendors that provide diagnostic testing so that results are communicated from the vendor directly into the patient’s medical record. Typically, there is some notification that a result is available for review, such as an icon, a pop-up dialogue box, or notification of a document in queue. In a paper chart, it is helpful to have a section of the medical record specifically for the results of such tests. These are usually filed in chronological order with the most recent results ac- cessed first. Diagnostic imaging reports, rather than the actual images, are usually kept in the patient’s record if the images were done at another location. Even when imaging studies are done on-site, the actual images are often stored in a separate location, and just the reports are kept in the medical record.

Noncompliance With Medical Treatment Health-care providers are obligated to educate and inform patients about their medical conditions, the treatment options available, the risks and benefits of each option, and the risks and benefits of no treat- ment at all. Despite your best efforts, patients will not always follow your recommendations. There are many reasons why a patient may be noncompliant with recommended treatment; some are unintentional and some are intentional. Some unintentional barriers to compliance may be the patient’s culture, language, religious practices or beliefs, lack of insurance coverage for certain treatments, or other socioeconomic factors. You should make every attempt to identify barriers and then assist the patient in becoming compliant if the patient desires to do so. Even when fully informed about the possible consequences of noncompliance, patients may choose not to follow a recommended treatment plan.

If a patient’s medical condition fails to improve, you must determine why. Failure to improve could mean that the patient has not been compliant with the recom- mended treatment, the patient has not been diagnosed

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Figure 8-3 Anticoagulant flow sheet.

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Figure 8-4 Sample demographic screen in an EMR.

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correctly, or the correct treatment has not been initiated. It is important to have a conversation with the patient, and perhaps family members or caregivers, to determine whether noncompliance is a factor. Ask the patient whether he or she is taking any prescribed medication; if so, is the patient taking it appropriately? Has the patient instituted recommended lifestyle changes? Is the patient getting diagnostic tests done or going to therapy? Has the patient consulted and followed up with the specialist? After exploring these considerations, try to ascertain the patient’s understanding of the ramifications of noncom- pliance. If the patient simply refuses to follow treatment recommendations, even when he or she understands the potential consequences of not following treatment, then the patient is considered to be noncompliant. You must document—in detail—the information discussed with the patient, including the potential consequences of continued noncompliance, as well as the patient’s re- sponse. “Noncompliance” should be documented in the assessment and on the problem list. The ICD-10 code Z91.19 may be used for noncompliance with medical treatment. Be sure to document in the plan portion any advice or education that you provided. Example 8.1 demonstrates one way to document a noncompliance note.

EXAMPLE 8.1

Noncompliance Note S: Mr. Graham, age 49, is here for follow-up on

hyper tension. He has not been taking the hydro- chlorothiazide 12.5 mg that was prescribed for him at the last office visit 2 weeks ago. He states, “I feel fine. I don’t need to take any medicine.” He denies chest pain, shor tness of breath, swelling in the feet or ankles, visual changes, or headache. He has been counseled on smoking cessation but continues to smoke a pack of cigarettes daily. At the last visit, I recommended that he tr y to exercise 20 to 30 minutes 3 days of the week, but he has not yet initiated any exercise. His mother died of a stroke at age 59, and his father died at age 51 from a myocardial infarction. He has a younger brother with hyper tension that is con- trolled with medication.

O: Mr. Graham is a well-developed, obese man, NAD. He appears agitated.

VSHt: 6 ft 2 in.; Wt: 265 lb; BP right 168/102, left 172/104; T 98.2 orally; pulse is 94 and regular ; respirations 20 per minute.

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Eyes: Pupils are round and reactive to light bilaterally. Discs are sharp with normal cup-to-disc ratio. Fundi are unremarkable without AV nicking or exudates.

Neck: No carotid bruits or JVD. Hear t: RRR without murmur, clicks, or gallops. Nor-

mal S1 and S2. Chest: Breath sounds CTA all fields. There is no in-

creased AP diameter of the thorax. Abdomen: Soft, nontender, no organomegaly or

masses, physiological bowel sounds. Extremities: No edema. Pedal pulses are 2+ and

equal bilaterally. UA: Specific gravity 1.012, no proteinuria or

hematuria. ECG: NSR without acute ischemic changes. CXR: No active disease, no cardiomegaly. A: (1) Uncontrolled HTN, recently diagnosed. I10

(2) Noncompliance; patient has refused treatment up to this point. Z91.19

(3) Obesity with BMI of 34. E66.01 (4) Tobacco use disorder. F17.200

P: Had 15-minute discussion with patient regarding hyper tension, its historical course with and with- out treatment, impor tance of taking prescribed medication daily, and potential complications of nontreatment, including stroke, hear t attack, and death. Discussed his personal and family risk fac- tors for these conditions. Also discussed HTN as the “ silent killer” and explained possible end-organ damage despite not having symptoms or feeling bad. He stated his understanding and had no questions. He expressed reservations about “star ting a pill that I will have to take forever.” The medication is cov- ered by his insurance, so medication access is not a barrier. He did agree to have the nurse at work check his blood pressure daily, and he will get the blood work done. He agreed to follow up here in 2 weeks but would not agree to star t the medication.

Communication With Other Providers A referral is when one health-care provider advises the patient to see another provider. A referral to see a spe- cialist may be required by the patient’s health insurance plan. Often, a referral or request for consultation is made when evaluation or management of a condition is beyond the scope of the referring provider’s training or experience. The consultant’s role may be to recommend further diagnostic testing, make a diagnosis, recommend a plan of treatment, or manage the patient’s condition, or a combination of these. To clarify the role of each provider, reference may be made to the referring provider and the consulting provider. It is the referring provider’s responsibility to specify the reason for the referral and the action desired so that the consulting provider knows whether to provide an opinion only or to manage the patient’s condition actively. Any information pertinent to the referral should be transmitted to the consulting provider for review and may include a written summary, progress notes, problem list, medication list, flow sheets, test results, other consultants’ notes, and sometimes hospital records. This communication between providers helps to avoid duplicating tests that have already been done or prescribing treatment that may have been tried previously but was not effective.

The primary care provider maintains responsibility for the overall health of the patient even when the patient is under a specialist’s care. Consulting providers are expected to communicate with the referring provider in a timely manner. Patient authorization is not needed for communication between providers; it is implied with the referral and necessary for continuity of care. The initial consultation note typically consists of a problem- specific history; a problem-focused physical examination; impression or assessment; and recommendations for care, management, or further workup. If the patient is to remain under the care of the consulting provider, then the consulting provider should keep the referring provider updated periodically on the patient’s condition and response to treatment. Many EMR systems will automatically generate a letter that includes history of present illness (HPI), pertinent past medical history (PMH), examination findings, and assessment and plan; some systems allow users to customize a letter template.

A comprehensive history and physical examination for Mr. William Jensen was provided in Figure 2-2. Part of the plan for the visit was to refer the patient to Dr. Michael Bennett for colonoscopy and biopsy. Figure 8-5 shows a letter from Dr. Scott to Dr. Bennett requesting assistance in the workup of this patient. Figure 8-6 shows a letter from Dr. Bennett to Dr. Scott with the results of the workup.

MEDICOLEGAL ALERT !

It is crucial to document noncompliance in a patient’s medical record. If it is not documented and the patient has a poor outcome, the patient or a family member may file a malpractice suit against you, claiming that you were negligent or did not care for the patient appropri- ately. You must document that you counseled the patient about the medical condition, discussed the risks and benefits of the recommended and alternative treatment options, and warned the patient about potential mor- bidity and mortality complications. Whenever possible, use direct quotes from the patient. Refrain from making any judgment statements about the patient; document objective observations only.

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Figure 8-5 Referral letter to Dr. Bennett.

Vernon Scott, MD 2000 Oak Street, Suite 311

Phoenix, AZ 85005 602-537-2000

Michael W. Bennett, MD Southwest Gastrointestinal Specialty Group 5700 E. VanHorn St., Suite 25 Phoenix, AZ 85002

RE: William R. Jensen DOB: March 30, 19XX

Dear Dr. Bennett,

Thank you for agreeing to see Mr. William R. Jensen. Mr. Jensen is a pleasant 67-year-old man who is a new patient to my practice. He presented to my office with complaints of fatigue and feeling weak. He also gave a history of a 10-pound unintentional weight loss over the past 2 months. His PMH is significant for hypertension and dyslipidemia, which have been stable with medical management. He is presently taking Lotensin HCT 20/12.5 once daily and Mevacor 20 mg once daily. He is allergic to penicillin, which gives him a rash. During workup at my office, he was found to have hemoccult-positive stools. His WBC is 5.8 and H&H 13 and 46. There is a family history of breast cancer. Mr. Jensen has had one colonoscopy approximately 15 years ago and no screening since.

Considering the fatigue, weight loss, and hemoccult-positive stool, I recommended to Mr. Jensen that he undergo colonoscopy with biopsy. He is scheduled to see you within the next 2 weeks. I have enclosed a copy of his CBC, CMP, and ECG for your review. Should you need additional information, please do not hesitate to contact me.

Sincerely,

Vernon Scott, MD

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Prior Medical Records When possible, you should review medical records from other providers and specialists if they are available. These records may be invaluable in filling in details and providing insight into the patient’s past medical history, especially when the patient has a chronic condition that requires ongoing care. It is particularly helpful to evaluate what treatments have been tried in the past and the efficacy of the treatments; this may help you avoid prescribing an ineffective treatment and may save time and money for both you and the patient. Use results of prior laboratory tests or diagnostic studies for comparison purposes. If a patient has been hospitalized, it is helpful to have a copy of the admission history and physical examination (discussed in Chapter 10) and the discharge summary (discussed in Chapter 12) in the medical records. Especially in instances in which the patient is managed by a hospitalist and not the patient’s primary health-care provider, having access to such documents helps to ensure continuity of care and provides accurate information pertaining to the patient’s

condition. In most instances, the admitting physician will indicate that a copy of the records should be sent to the primary health-care provider. At times, the patient may need to request a copy of his or her records from the hospital and give them to the provider. Reviewing other records adds to the complexity of the evaluation of the patient, so you should specifically document that outside records were reviewed to help support the billing level for evaluation and management.

Documenting Communications With Patients Telephone Communication Communication with patients frequently occurs outside an office visit. Telephone communication is a common means of exchanging information between patients and health-care providers. The scope of telephone calls extends beyond the basic call to the provider’s office to arrange an appointment. Calls are often requests

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Figure 8-6 Consultation letter from Dr. Bennett.

Michael W. Bennett, MD Southwest Gastrointestinal Specialty Group

5700 E. VanHorn St., Suite 25 Phoenix, AZ 85002

Vernon Scott, MD 2000 Oak Street, Suite 311 Phoenix, AZ 85005

RE: William R. Jensen DOB: March 30, 19XX

Dear Dr. Scott,

It was a pleasure to see Mr. William Jensen for consultation regarding his weight loss and fatigue. Prior to the colonoscopy, Mr. Jensen sent in three stool sample cards, two of which were positive for blood. A colonoscopy was performed at the outpatient surgical center; he tolerated the procedure well. GI prep was adequate. Several suspicious polypoid lesions were visualized at the hepatic flexure area. Multiple biopsies were obtained, and there were no complications.

The pathology report confirms the diagnosis of adenocarcinoma of the colon. I met with Mr. Jensen and his wife yesterday to discuss the diagnosis and usual course of surgical management. I recommended that he see Dr. David Sanders for more information on the various surgical approaches. Mr. Jensen was agreeable with this and will call for an appointment.

I have enclosed a copy of the pathology report for your records. Thank you for allowing me to participate in the care of this patient. If he elects surgery, I would be happy to follow him with you. Please call me if any questions.

Respectfully,

Michael W. Bennett, MD

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for medical advice or are a means of providing other information, such as results of diagnostic tests. There- fore, the conversation that occurs by telephone is still an important part of the patient–provider relationship and, as such, is subject to documentation in much the same way as other medical visits. Medicare and many private insurers do not reimburse for telephonic com- munications. Some third-party payers will pay if the calls are coded properly. A billable call can be initiated only by an established patient or the patient’s guardian. The conversation cannot be related to a face-to-face appointment that occurred within the past week or will happen within the next 24 hours or the next earliest available appointment. In other words, the call has to substitute for in-office care. The relevant Current Pro- cedural Terminology (CPT) codes, which reflect the number of minutes of medical discussion, for physicians are 99441 (5 to 10 minutes), 99442 (11 to 20 minutes), and 99443 (21 to 30 minutes). The comparable codes for care provided by other health professionals are 98966, 98967, and 98968. To increase the likelihood of payment, you must document the call like an in-person visit with notation of the time spent (Torrey, 2017).

Each practice should develop protocols identifying which calls must be directed to a health-care provider immediately, which calls may be returned later, and which calls may be handled by another professional or office staff. If members of the professional staff are authorized to give telephone advice, there should be written protocols to define the scope of the staff member’s authority to give such advice to minimize the likelihood of staff practicing medicine without a license and outside their scope of training.

Some practices use a telephone call log to document every call. If used, such logs should be retained as long as medical records are retained. Others may use spe- cific forms, such as the one shown in Figure 8-7, for documenting telephone calls. Regardless of how the documentation is done, the same information should be documented consistently. This includes the date and time of the call, patient’s name, name of caller and relationship to the patient, the complaint, advice given, follow-up plan, and disposition. Be sure the advice is documented in detail, and, ideally, you should ask the caller to repeat it so you can verify that the caller understood the advice given. Failure to document may

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lead to liability related to failure to diagnose, delay of treatment, improper treatment, failure to follow up, and breach of confidentiality.

If you attempt to reach a patient by telephone but are unable to do so, document your attempts, including the date and time of each attempt. Before leaving messages on an answering machine or with someone other than the patient, ensure that consent has been obtained from the patient. The consent should indicate specifically if and with whom messages may be left. Document in the patient’s record that a message was left. Never leave clinical information or advice as a voice message; instead, leave your name and a telephone number and request a call back.

Electronic Mail Telephone communication between health-care provider and patient is not without its frustrations. Providers often view calls as unnecessary interruptions. Patients express frustration that they may have to wait to receive a call back from the provider. Several studies have shown that patients would prefer communicating with providers by electronic mail (e-mail); in one study (Stouffer, 2008), 90% of respondents wanted their providers to use e-mail

communication. Like other modes of communication, there are advantages and disadvantages to using e-mail.

Benefits of E-mail One of the greatest advantages is the convenience for patients and providers. A patient can send an e-mail and receive a response without staying on hold or wait- ing by the telephone. Patients believe that requesting prescription refills, obtaining routine test results, and scheduling appointments by e-mail saves time (Rajecki, 2009). Zhou and colleagues (2007) found that the use of e-mail and electronic messaging decreased the amount of time that providers spent on the telephone. Another advantage is that e-mail creates a documentation trail that can be used to record activity and conversation, providing a transcript of all that is said and not said, in an electronic format.

Concerns Regarding E-mail There are perceived and real disadvantages to using e-mail. One of the disadvantages that is cited most frequently is related to revenue. A study at one large health maintenance organization (HMO) reported a

Figure 8-7 Telephone call log form.

Peoria Pediatrics Telephone Log Form

Date: ___/___/___ Time: ____________________

Caller/Relationship: _________________________________________________________________________________________

Patient: _________________________________________________________________________ Age: ____________________

Reason for call: ____________________________________________________________________________________________

HPI/PMH: _________________________________________________________________________________________________

__________________________________________________________________________________________________________

Medications: _______________________________________________________________________________________________

Allergies: __________________________________________________________________________________________________

Diagnosis: _________________________________________________________________________________________________

Recommendations/Rx: _______________________________________________________________________________________

Disposition: ________________________________________________________________________________________________

Follow-up: _________________________________________________________________________________________________

__________________________________________________________________________________________________________

Pharmacy: _______________________________________________ Phone: ___________________________________________

Billing:

Brief (99371) Intermediate (99372)

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decrease in annual office visit rates among patients who had online access to their provider (Zhou et al, 2007). A decrease in office visits could mean decreased income for the provider because office visits are billable visits. Only a few private insurance plans reimburse the provider for “e-visits” or “virtual visits” conducted by e-mail. Accord- ing to the American Health Information Management Association (AHIMA), the lack of reimbursement from Medicare is a limiting factor in the number of providers using e-mail. If the Medicare policy were to change, it is likely that e-mail communications between provider and patient would increase. Medicare does reimburse for some live telemedicine services, not just electronic communications, and specific criteria must be met for the visit to be reimbursable. Patients must be physically present at qualifying clinical sites, which must be in an area defined by the Centers for Medicare and Medicaid Services (CMS) as rural and underserved, a definition that excludes as many as 80% of Medicare beneficiaries ( Joseph and Stuhan, 2015). More information about the criteria for telemedicine visits is available at www .cms.gov/Outreach-and-Education/Medicare-Learn- ing-Network-MLN/MLNProducts/Downloads/Tele- health-Services-Text-Only.pdf. Currently, all but three state Medicaid programs pay for virtual visits, although different states have different requirements for what types of services can be provided under virtual visits and where. However, because Medicaid is administered in a state-by-state manner, no two programs are identical in terms of coverage.

Confidentiality and protected health information (PHI) are other concerns with e-mail or electronic messaging. State and federal laws vary when it comes to patient privacy, particularly for patient conditions such as sexu- ally transmitted diseases (STDs), HIV, substance abuse, and treatment for mental health conditions. Laws about e-mailing patients who seek care for these conditions are very stringent and may cause confusion for providers. The Health Insurance Portability and Accountability Act (HIPAA) requires that electronic PHI, including e-mail, be communicated in a secure way, that is, through an encrypted system. There are many commercial services available that provide encrypted communication, but providers may be unwilling to pay for these services. In addition, patients may be unwilling to use encryption services to communicate with providers when their unencrypted e-mail system is quick and simple to use. Safeguarding the confidentiality of e-mail messages is difficult. Confidentiality can be breached by outsiders (hackers) or by patients and providers themselves who reply to or forward e-mails to individuals outside the patient–provider relationship. E-mails may be intercepted, altered, or delivered to the wrong address, resulting in people other than the intended recipients having access to the e-mail communication.

Many providers have concerns about potential legal problems. E-mails are still provider–patient commu- nication and are discoverable—even deleted ones. A poorly written e-mail may be used to portray you as unprofessional. Before sending a message, be sure to double-check your e-mails for accuracy and appropriate language. Flippant or humorous messages may look disrespectful when viewed later, out of context.

Other concerns about the use of e-mail have been identified. Providers may fear being bombarded by e-mails or having patients abuse the privilege. It may be difficult to confirm the identity of the patient in an e-mail request. Messages can be delayed by hours or even days, and not receiving a response in a timely manner may have adverse health consequences. Patients may e-mail about multiple complaints or problems. Viruses may be transmitted through attachments that may cause serious damage to computer systems. Patients may come to expect a quick response to e-mail. Limiting e-mails to English only may cause problems for patients with limited English proficiency. A certain level of patient literacy is required for the e-mail exchange to be beneficial and efficient.

Provisions for Using E-mail If the decision is made to communicate with patients by e-mail, specific actions must be taken. Obtain written permission from patients to communicate with them by e-mail. Set expectations and limitations with patients about what they can e-mail and how long it will take to respond. Develop policies for the use of e-mail, in- cluding how e-mail messages will be incorporated into the patient’s medical record. Most EMR systems have a feature that will archive e-mails in the patient’s record. If this feature is not available, or if an EMR system is not used, e-mails should be printed and saved in the patient’s medical record. Provider–patient e-mails are considered health-care organization business records and, therefore, are subject to the same provisions for storage, retention, retrieval, privacy, and security and confidentiality as any other patient-identifiable health information. Confirm that you have the correct e-mail address for the intended recipient. Ensure that PHI sent by e-mail is encrypted with access provided only to authorized individuals who have an access code. Add a confidentiality disclaimer to e-mail messages that states the content is confidential and intended only for the stated recipient. The disclaimer also should state that anyone receiving the e-mail in error must notify the sender and return or destroy the e-mail as per the request of the sender. Never use e-mail distribution lists to send personal information.

For those providers who choose to utilize e-mail, you can follow the American Medical Association’s Guidelines for Patient-Physician Electronic Mail (Policy H-478.997; 2012). The American College of Physicians (ACP)

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and the Federation of State Medical Boards (FSMB) Special Committee on Ethics and Professionalism developed a position paper that examines and provides recommendations about use of e-mail and other Web- based communication platforms. The consensus is that e-mail is best used as an extension of the patient–provider relationship and not a replacement for the relationship. Finally, be sure you are familiar with and follow state laws governing the use of e-mail communications.

Patient Portal A patient portal is a secure online Web-based platform that gives patients convenient 24-hour access to their own or a family member’s health information and EMRs from anywhere with an Internet connection. Also, patient portals offer self-service options that can eliminate “phone tag” with the health-care provider. The features of patient portals vary, but typically patients can schedule appointments; request medication refills; and securely view and print portions of their medical record, including visit notes, discharge summaries, medications, immunizations, allergies, and most laboratory results. Other features may include downloading or completing intake forms, exchanging secure e-mail with members of the health-care team, checking benefits and coverage, updating contact information, and making payments. Sometimes the patient portal can be used to send ap- pointment reminders to patients and to identify and provide patient-specific educational resources. Many hospitals offer patient portals similar to those used in ambulatory care settings. Some hospital systems also offer a platform where patients (or their representative) can update friends and family about their health status. Patients also may use the portal to find a health-care provider or enroll in educational classes.

Social Media Benefits of Social Media Social media refers broadly to Web-based tools that allow individuals to communicate quickly, easily, and broadly. Many health-care organizations are using social media to engage with patients and consumers. Health-care organizations also use social media to communicate their mission and vision, describe the services they offer, and provide health education. Some organizations use social media to promote wellness and sponsor online support forums where individuals who are dealing with chronic health issues or catastrophic conditions can find support from others who are having similar experiences. On some sites, physicians and other clinicians educate the public on common diseases, what can be done to cope with conditions, and how to maximize the quality of life for the individual who is suffering from the disease.

Patients often use the Internet and social media sites to educate themselves about medical conditions and treatment options. Information obtained from websites may have tremendous influence on patients, whether or not that information is credible or supported by medical research. A portion of the medical encounter may be spent discussing information that the patient brings to the visit, especially when you may have to educate patients on the inaccuracy of information.

Sites devoted to specific diseases or conditions, from asthma to Zollinger-Ellison syndrome, are plentiful. Patients may access educational material, connect with other people with the same condition, and find providers who specialize in treating their condition. As a provider, you may find medical websites helpful to obtain clinical information about diseases, participate in continuing education programs, and collaborate with other providers across the country and around the world. Although Web-based platforms continue to be used in these “traditional” ways, they are increasingly used as a means of social networking.

Social media sites, such as Facebook, Twitter, and Google Plus, have evolved from a preoccupation of high school and college students to the mainstream of social interaction that spans divisions of age, profession, and socioeconomic status. Several provider-only sites, such as Sermo, Ozmosis, PA-CLife, and Nurse LinkUp, offer providers the chance to connect with others in their profession for knowledge sharing, networking, and support. Access to these sites is controlled so that providers are able to share opinions and interact in a safe, guarded environment. Providers may be required to disclose their name and credentials, preventing users from hiding behind a cloak of anonymity. Registered users of many online medical communities can flag information they believe is inappropriate, which en- hances the quality of the information posted on the site.

Although these types of professional sites are growing in number and popularity, many providers are also turning to social media for professional reasons or networking. Hospitals and health-care systems use social media to communicate with colleagues and patients. A 2014 study reported that more than 3,000 hospitals have accounts on at least one social media site, and approximately half of all U.S. hospitals have an account on at least four sites. A number of hospitals have blogs authored by the chief executive officer in an effort to personalize their message. Proponents of social networking cite benefits, such as an increased presence in the community, the ability to promote certain services, and marketing to attract new patients. Others indicate that the use of social networking offers a way to stay abreast of medical news, share practice management tips, and build consensus on issues important to them. The ease of facilitating communication is also an advantage, particularly when

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communicating findings from research. New findings can be disseminated through social media the minute they are learned, putting useful information in the hands of clinicians more quickly than the traditional dissemination through professional journals or meet- ings. Often clinical research is sponsored by industry, and few people may evaluate the content before it is published in a journal. In an online community, review by potentially thousands of professionals may promote superior credibility.

Concerns About Social Media Despite the benefits of social media, there are also con- cerns and challenges. Perhaps the greatest concern—and the reason to include the topic of social media in a text on documentation—is the permanence of information posted on sites. Of equal concern is that there is no anonymity on the Web. Information posted on most social media sites is indexed on Google and can be found by patients, supervisors, potential employers, attorneys, and others. Even when information is removed from a site, it is usually archived somewhere and accessible in the future. Lawsuits have been filed against physicians and other health-care providers for posting photographs of patients without their consent. Before posting in- formation on a social site, health-care providers should consider how the content would likely be interpreted in various settings, such as an interview, a departmental meeting, or during litigation. The information, whether in written form or photographs, should be considered permanent documentation that can be accessed by anyone at any time. The tourism industry in Las Vegas launched a successful campaign based on the idea that “what happens in Vegas stays in Vegas.” Health-care providers who have a presence on social media should operate on the premise that “what happens in Vegas shows up on the Internet the rest of your life.”

Another concern related to social media is the potential to breach patient confidentiality. Even with the best of intentions, it is easy to divulge PHI when posting a case and seeking input from colleagues. Any information that is shared should be generic enough that no one can identify a patient in the course of reading a post. Another challenge is the blurring of the boundaries of the patient–provider relationship and the merging of professional and personal lives. Providers must decide whether they will accept a request from patients to engage in a social media relationship. Although many websites allow users to choose privacy settings and to control which personal content is available to whom, once information is posted on social media, there is no longer any control over that information. Providers also should realize that information could be posted on other sites and could be viewed as providing medical advice, resulting in a liability risk.

Provisions for Using Social Media Social media is likely here to stay. Health-care pro- fessionals need to carefully consider whether to have a presence on social media. If the decision is made to do so, it is recommended that separate sites be used for professional and personal purposes to maintain ap- propriate boundaries. A position paper from the ACP and FSMB published in 2016 examines and provides recommendations about the influence of social media on the patient–provider relationship, the role of these media in public perception of physician behaviors, and strategies for provider–patient communication that pre- serve confidentiality while best using these technologies. On any site to which patients have access, a disclaimer should be used to state clearly that the provider is not giving medical advice to individuals. Guidelines for postings should be established, as should guidelines for dealing with “friend” requests. The FSMB specifically discourages physicians from interacting with current or past patients on personal social networking sites. Students in professional programs and licensed pro- viders should take extra precautions to ensure that they are not in violation of policies of the school, employer, or professional liability carrier or the ethics codes of a hospital or professional society. Remember that social media sites are not HIPAA-compliant and should never be used for any patient–provider communication.

By applying these commonsense principles, provid- ers should be able to realize the benefits and protect themselves from the perils of social networking.

Summary In addition to SOAP notes, you may use other forms of documentation, such as problem lists, medication lists, and flow sheets, to document a patient’s medical information. Correspondence between medical providers should be incorporated into the patient’s medical record. Demographic and billing information may be kept in the patient record, often in a section that is separate from medical information. If you or your institution decides to allow e-mail between patients and providers, all e-mails should be made a permanent part of the patient record. EMRs and Web-based patient portal platforms will have a system design that promotes security of protected health information and that captures who accesses the patient’s record. Health-care providers and institutions should develop and prominently display procedures and guidelines for use of e-mail or patient portals, and they must have policies that deal with se- curity breaches. To reinforce the content of this chapter, please complete the worksheets that follow. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

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Worksheet 8.1

Name:

Review

1. In addition to a SOAP note, identify at least four types of documentation that could be kept in a patient’s

medical record.

2. Explain the rationale for using a medication list.

3. Figure 8-3 shows a flow sheet used to track information for a patient who is on anticoagulation therapy.

Identify at least three other conditions for which a flow sheet might be used and the information that

could be included.

4. Identify at least four components of a telephone call that should be documented and placed in the pa-

tient’s medical record.

5. Identify three advantages to using e-mail to communicate with patients.

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6. Identify three disadvantages to using e-mail to communicate with patients.

7. Identify three benefits that providers, hospitals, or health systems can realize with social media.

8. List three concerns related to providers having a presence on social networking sites.

9. Identify at least three recommendations to providers who choose to have a presence on a social network-

ing site.

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Worksheet 8.2

Name:

Recording Telephone Calls

The narrative of a telephone conversation between Mariel Novak, FNP, and Cindy Florinda, mother of a

15-month-old boy, is shown next. Use the information in the narrative to fill in the telephone log form

provided in Figure 8-7.

MN: Hello, may I speak with Cindy?

CF: This is Cindy.

MN: Hi, Cindy. This is Mariel, the nurse practitioner at Peoria Pediatrics. I’m returning your phone call. How may

I help you?

CF: I’m calling about my son Tyler. He is running a fever, and he has a rash. I’m concerned.

MN: How old is Tyler?

CF: He is 15 months old.

MN: Is Tyler on any regular medications?

CF: No.

MN: Is he allergic to any medications?

CF: No.

MN: When did he start running a fever?

CF: Last night around 8 p.m. I’ve been giving him Children’s Advil, but his temperature goes back up.

MN: How much does Tyler weigh?

CF: He’s about 22 pounds.

MN: And how much Advil did you give him?

CF: I think it is 200 mg. Let me check on the bottle. (Pause) Yes, it is 200 mg. Is that OK?

MN: Yes, that is the correct dose for his weight. Is Tyler having other symptoms, like runny nose, coughing,

vomiting, or diarrhea?

CF: He has had a runny nose for a few days. Nothing else except the rash.

MN: When did you notice the rash?

CF: He had it when he woke up this morning.

MN: Does he scratch or seem to be bothered by the rash?

CF: No, he doesn’t.

MN: Is he eating and drinking fluids?

CF: He doesn’t seem to be as hungry as he normally is, but he is drinking OK.

MN: When was the last time he wet his diaper or urinated?

CF: About 4 hours ago.

MN: Is anyone else in the household ill?

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CF: No, everyone else is fine.

MN: How would you describe his activity?

CF: When his temperature is up, he acts grumpy, but when it comes down, he seems to be fine. He did take a

longer nap today than usual.

MN: When was the last time Tyler was at the office?

CF: I took him in about a week and a half ago for a nurse visit. They gave him a shot. I think it was the MMR

vaccine.

MN: Has Tyler ever had reactions or problems after other vaccines?

CF: No.

MN: Let me be sure I’ve got everything. Tyler started running a fever last night and had a rash this morning. He

doesn’t have runny nose, cough, or vomiting, and he is drinking fluids OK and urinating. He got the MMR vac-

cine about a week and a half ago. He is a little grumpy when his temperature is up but otherwise seems to

be OK. Is there anything else you can think of?

CF: No, that’s all.

MN: Does he have any swelling or redness where they gave him the shot?

CF: No.

MN: Cindy, I think Tyler’s symptoms are related to the MMR vaccine he got. It is fairly common for children to

develop a fever and sometimes a rash 1 to 2 weeks after getting the vaccine. This doesn’t necessarily mean

that he is having a reaction to the vaccine. It is more likely that the measles part of the vaccine is starting to

work. I think it is OK to continue giving him the Advil for fever. You can give it every 6 hours, and keep the

dose at 200 mg. His appetite might be decreased for a few days, but as long as he is drinking fluids OK, he

should be fine. You want to keep an eye on his urine output. If he goes longer than 6 hours without wetting

a diaper or urinating, he could be getting dehydrated, and I want you to call back if that happens. Do you feel

comfortable with this plan?

CF: Yes. I just hope his fever doesn’t last too long.

MN: If he has fever for more than 48 hours, you should bring him in to the office so we can have a look at him,

OK? Also, if he starts to get real drowsy and you have a hard time waking him up, you should call right away.

CF: OK.

MN: Do you have any questions?

CF: No. I appreciate you calling me back so soon. Thanks.

MN: You’re welcome. I hope Tyler is feeling better soon. Remember to call if his fever lasts for more than

48 hours, if he goes more than 6 hours without urinating, or if he gets really drowsy or lethargic and you

can’t wake him up.

CF: OK, I will. Goodbye.

MN: Goodbye.

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Worksheet 8.3

Name:

Abbreviations

These abbreviations were introduced in Chapter 8. Beside each, write the meaning as indicated by the context

of this chapter.

ACP

AHIMA

CPT

EMR

HIPAA

HPI

INR

PHI

STD

ACE

CMS

ECG

FSMB

HMO

ICD

OTC

PMH

SSN

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195

Prescription Writing and Electronic Prescribing LEARNING OUTCOMES

• Discuss the role of the Drug Enforcement Agency (DEA) in regulating controlled substances. • Discuss federal and state laws that govern prescribing authority. • Identify safeguards for prescribers to protect their DEA number and prevent prescription

tampering and fraud. • Define controlled substances and noncontrolled substances. • Identify required elements of a prescription. • Identify dangerous abbreviations that should be avoided. • Identify common prescription-writing errors. • Define electronic prescribing (e-prescribing). • Discuss key federal initiatives that have been part of the impetus for e-prescribing. • Identify the criteria for qualified e-prescribing. • Discuss benefits of and barriers to e-prescribing.

Introduction According to the National Ambulatory Medical Care Survey, 922.6 million visits were made to office-based health-care providers during 2013. In more than two thirds of these visits, there was “mention of medications,” which is defined as medications provided, prescribed, or continued. At 40% of all visits, two or more drugs were recorded. According to the QuintilesIMS Health Report, more than 4.45 billion prescriptions were dispensed by retail pharmacies in the United States in 2016. It has been estimated that another 1 billion prescriptions are written each year that are never filled.

The medication use process is particularly susceptible to errors because of a number of reasons:

• The large number of drugs available • A lack of precisely defined best practices • Confusion between drug names, dosage forms,

routes of administration, doses, and units of dose measurement

The number of look-alike and sound-alike drug names is a matter of such concern that the Food and Drug

Administration (FDA) has instituted a program to better distinguish between them. Additionally, the FDA approves one or two new drugs each week and makes a dozen or so changes in indications for cur- rent medications already approved. Physicians, nurse practitioners, and physician assistants cannot possibly keep up with all the relevant information available on all the medications they might prescribe. When you factor in handwritten prescriptions and the number of steps between writing a prescription and dispensing a medication, it is easy to see how errors can occur.

In 2010, Kaushal and colleagues published a study that evaluated prescription errors in community-based office settings. They found that prescribing errors were higher than what had been previously reported with a range of 37.3 to 42.5 per 100 paper-based prescrip- tions containing errors. The most commonly identified errors were inappropriate abbreviations, duration errors (how long to take the medication), and direction errors ( instructions for how patients should use the medication). There were 87.6 illegibility errors per 100 prescriptions, the most frequent type of which were illegible signature and strength or strength units. The study participants were divided into two groups: those who continued

Chapter 9

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196 | Guide to Clinical Documentation

to handwrite prescriptions and those who adopted electronic prescribing (or e-prescribing). At the end of the study, there was no significant rate of change statistically among errors in paper-based prescriptions. In the e-prescribing group, error rates decreased nearly sevenfold from 42.5 per 100 prescriptions to 6.6 per 100 prescriptions. Illegibility errors were completely eliminated. E-prescribing is discussed in detail later in this chapter. However, before looking at e-prescribing, it is necessary to understand the basic concepts related to prescribing, such as the role of the Drug Enforcement Agency (DEA), state and federal laws that govern pre- scribing authority, and controlled versus noncontrolled substances. Likewise, a prescriber must understand the elements that are required in a prescription regardless of the means by which the prescription is generated.

Federal and State Regulations and Prescribing Authority The DEA was established in 1973 to serve as the pri- mary federal agency responsible for the enforcement of the Controlled Substances Act (CSA). The CSA sets forth the federal law regarding both illicit and lawful (pharmaceutical) controlled substances. With respect to pharmaceutical controlled substances, the DEA’s statutory responsibility is twofold: to prevent diversion and abuse of these drugs while ensuring that an adequate and uninter- rupted supply is available to meet the country’s legitimate medical, scientific, and research needs. In carrying out this mission, the DEA works in close cooperation with state and local authorities and other federal agencies.

Under the framework of the CSA, the DEA is responsible for ensuring that all transactions related to controlled substances take place within the “closed system” of distribution established by Congress. Under this closed system, all legitimate handlers of controlled substances—manufacturers, distributors, practitioners, pharmacies, and researchers—must be registered with the DEA and maintain strict accounting for all distributions. Under the CSA, the term practitioner is defined as “a physician, dentist, veterinarian, scientific investigator, pharmacy, hospital, or other person licensed,

registered, or otherwise permitted, by the United States or the jurisdiction in which the practitioner practices or performs research, to distribute, dispense, conduct research with respect to, administer, or use in teaching or chemical analysis a controlled substance in the course of professional practice or research.”

Every person or entity that handles controlled sub- stances must be registered with the DEA or be exempt by regulation from registration. The DEA registration grants practitioners federal authority to handle controlled substances. The registration is used to track practitioners’ prescribing practices related to controlled substances and to control the unauthorized prescribing of controlled substances. Each qualified practitioner is assigned a unique DEA identifier number. A prescription for a controlled substance that does not have an authorized DEA number on it cannot be filled. The DEA provides a practitioner’s manual to assist prescribers in understanding their re- sponsibilities under the CSA and to provide guidance in complying with federal regulations. The manual may be found at the DEA’s website at www.DEAdiversion. usdoj.gov. Any DEA-registered practitioner may engage in only those activities that are authorized under state law for the jurisdiction in which the practice is located. When federal law or regulations differ from state law or regulations, the practitioner is required to abide by the more stringent aspects of both the federal and state requirements. In many cases, state law is more stringent than federal law and must be complied with in addi- tion to federal law. If a state requires a separate license for controlled substances, then it should be obtained first and should be included in the federal application. Practitioners should be certain that they understand the regulations from their state as well as the DEA related to controlled substances. DEA regulations prohibit a physician from delegating the use of his or her signature and DEA registration to another person. Therefore, if a nonphysician provider is delegated the authority to prescribe controlled substances, then the provider also must be registered with the DEA. Prescribing authority for both physician assistants and nurse practitioners by state may be viewed at www.deadiversion.usdoj.gov/ drugreg/practioners/mlp_by_state.pdf.

Use the practitioner’s manual from the DEA to answer the questions in Application Exercise 9.1.

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Chapter 9 Prescription Writing and Electronic Prescribing | 197

Since October 1, 2008, all written prescriptions for outpatient drugs prescribed to a Medicaid beneficiary were required to be on tamper-resistant prescriptions containing specific characteristics as outlined by the Centers for Medicare and Medicaid Services (CMS). The law applies only to written prescriptions for covered outpatient drugs; prescriptions that are transmitted from the prescriber to the pharmacy verbally, by fax, or through an e-prescription are not impacted by the statute, and so those methods may be used as alterna- tives to a written prescription. The tamper-resistant characteristics are as follows: • One or more industry-recognized features

designed to prevent unauthorized copying of a completed or blank prescription form

• One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber

• One or more industry-recognized features designed to prevent the use of counterfeit prescription forms

Rather than having to take the time to identify Medicaid patients, most prescribers use the same prescription blanks for all patients. Additionally, most states have their own requirements for tamper-resistant prescriptions. More information about state requirements can be found at www.cdc.gov/phlp/docs/menu-prescriptionform. pdf. An example of a tamper-resistant prescription is shown in Figure 9-1.

Safeguards for Prescribers In enforcing the CSA, it is the DEA’s responsibility to ensure that drugs are not diverted for illicit purposes. Unfortunately, the United States is now experiencing an alarming problem with prescription drug abuse. More than 6 million Americans are abusing prescription drugs—that is more than the number of Americans abusing cocaine, heroin, hallucinogens, and inhalants combined. Researchers from the Centers for Disease Control and Prevention (CDC) reported more than 52,000 opioid-related deaths in 2015—more deaths than cocaine and heroin combined. All prescribers have an obligation to protect their DEA number and minimize the risk of prescription forgery and tampering.

In addition to the federally required security controls, practitioners can use additional measures to ensure security of paper-based prescriptions:

• Keep all prescription blanks in a safe place where they cannot be stolen; minimize the number of prescription pads in use.

• Write out the actual amount prescribed in addi- tion to the numerical value to discourage alter- ations of the prescription.

• Use prescription blanks only for writing a prescription and not for notes or orders such as laboratory or other diagnostic tests.

• Never sign prescription blanks in advance. • Assist the pharmacists when queries are made to

verify information about a prescription order; a

Application Exercise 9.1 Look up Percocet and identify its schedule. List the generic name of the medication and the strengths that are available.

Using the information found on the DEA website, identify the prescribing limits for Percocet tablets by a physician assistant practicing in Montana.

Using the information found on the DEA website, determine the maximum number of Percocet tablets that may be prescribed by a nurse practitioner practicing in Michigan.

Application Exercise 9.1 Answer Percocet: Schedule II; generic is oxycodone/acetaminophen. It is available in tablets of 2.5/325; 5/325; 7.5/325; and 10/325.

Prescribing limit for Percocet tablets by a physician assistant practicing in Montana: 34-day supply

Prescribing limit for Percocet tablets by a nurse practitioner practicing in Michigan: 30-day supply

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198 | Guide to Clinical Documentation

Figure 9-1 Tamper-resistant prescription pad. Author Author's review

(if needed)

Initials Date

OK Correx

ISBN #

Fig. #

Artist

B / W 4/C 2/C

Document name

Date

Check if revision

Sullivan 6662

F09_01 6662_C_F09_01.eps

AB/CO

Final Size (Width X Depth in Picas)

41p0 x 50p10

04/05/18 Editor's review

Initials Date

OK Correx2nd color PMSX

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Chapter 9 Prescription Writing and Electronic Prescribing | 199

corresponding responsibility rests with the phar- macist who dispenses the prescription to ensure the accuracy of the prescription.

• Contact the nearest DEA field office to obtain or furnish information regarding suspicious prescrip- tion activities.

• Do not include your DEA number on preprinted prescription blanks. Instead, leave a blank line and write in the number only when required for a controlled substance.

• Keep an inventory of the number of prescrip- tion pads you have on hand, making it easier to identify whether pads are missing.

• Do not use your DEA number as an identifier if there is another option (such as a National Provider Identifier [NPI] number). Using your DEA num- ber for identification increases the risk of misuse and the possibility of forged prescriptions.

• Do not display your DEA certificate. File it in a locked cabinet.

• Limit the number of people who have access to your DEA number. Instruct office staff to refer all requests for your DEA number directly to you.

Controlled and Noncontrolled Substances The drugs and other substances that are considered controlled substances under the CSA are divided into five schedules. A complete list of the schedules is up- dated and published annually in the DEA regulations, Title 21 of the Code of Federal Regulations, Sections 1308.11 through 1308.15. Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States and on their relative potential for abuse and likelihood of causing dependence when abused.

All drugs listed in Schedule I have no currently accepted medical use and, therefore, may not be prescribed, admin- istered, or dispensed for medical use. In contrast, drugs listed in Schedules II through V all have some accepted medical use and, therefore, may be prescribed, adminis- tered, or dispensed. Table 9-1 presents the categories of controlled substances as defined by the CSA.

Elements of a Prescription Certain elements should be included in every prescrip- tion, whether it is for a noncontrolled or a controlled substance. The basic elements include the following: • Date the prescription was written • Prescriber identification

• Patient identification • The inscription • The subscription • Signa • Indication • Refill information • Generic substitution • Warnings • Container information • Prescriber’s signature

A summary of these elements is shown in Table 9-2.

Writing Prescriptions for Noncontrolled Medications Prescriber Identification In many cases, this is preprinted on a standard prescription form. This includes the name and title of the prescriber and the address and telephone number of the practice or institution. When the prescriber is a nonphysician, some states require that the supervising physician’s name be printed on the prescription form as well.

Patient Identification This includes the patient’s name, address, age or date of birth, and, sometimes, weight. It is recommended and, in some states it is required, that you use the patient’s legal name instead of a nickname. If you are unsure of the patient’s legal name, ask to see a driver’s license or an insurance card if available. This helps avoid confusion and correctly identifies the patient. The date of birth is more commonly requested than the patient’s age

Schedule Comments I High potential for abuse. No accepted

medical use. II High potential for abuse. Use may lead

to severe physical or psychological dependence.

III Some potential for abuse. Use may lead to low to moderate physical dependence or psychological dependence.

IV Low potential for abuse. Use may lead to limited physical or psychological dependence.

V Subject to state and local regulations. Abuse potential is low.

Table 9-1 Drug Enforcement Agency Classification of Controlled Substances*

*As in the Controlled Substances Act of 1970. Drugs are categorized according to their potential for abuse: the greater the potential, the more severe the limitations on their prescription.

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200 | Guide to Clinical Documentation

because it allows more specific identification. When a prescription is written for a pediatric patient, you should include the patient’s weight so that the pharmacist can verify that the medication has been dosed appropriately.

Inscription This includes the name and strength of the medication. Generic or trade names may be used. Avoid abbreviating names of medications to help reduce the possibility of error. There are exceptions for well-known medications; for instance, trimethoprim-sulfamethoxazole is commonly abbreviated TMP/SMX. The strength is the amount per dosing unit, such as a 50 mg tablet or 250 mg per 5 mL. Some medications come in many different strengths and forms (i.e., tablets and liquids). If you are unsure which strengths and forms are available, you should consult a pre- scribing guide, pharmacology text, or medication reference book. The strength is not the same as the total amount to be taken by the patient over the course of the prescription.

Subscription This provides information to the pharmacist on dos- age form and number of units or doses to dispense. Instructions about the dosage form may be tablets, capsules, or suspension, for example. If a liquid or semiliquid is to be dispensed, provide the quantity, such as how many milliliters of suspension or how many grams in a tube. The amount dispensed should be the amount needed to complete a course of treat- ment. For example, if a patient is to take a tablet twice a day for 10 days, the subscription, or amount to dispense, would be 20 tablets. You will often see “#20” or “Disp: 20 tabs”; either is acceptable. Many patients use a mail-order pharmacy service provided by their health insurance plan administrator. Such mail-order pharmacies may have specific requirements

on how the quantity should be written and refill information, so it is recommended that you ask the patient whether he or she uses a mail-order service before writing the prescription.

Signa or sig This provides instructions to the patient on how to take the medication and should be as specific as possible. It should include the route; any special instructions, such as to take on an empty stomach or take with food; and how often to take. When the medication is prescribed on a prn basis, the reason for taking the medication should be included. Avoid writing vague or ambiguous instructions, such as take as directed or apply in usual manner. Numerous studies have documented that patients usually do not remember all the information they are given during the course of a provider–patient encounter; therefore, it is necessary to provide instructions that are as detailed and accurate as possible to reduce the chance that the medication may be taken inappropriately.

Indication Including the indication for the prescription is mandatory in some states. Even when states do not require an indica- tion, the Institute for Safe Medication Practices (ISMP) recommends including it for two reasons. First, many drugs have names that look and sound alike but are taken for very different reasons. Second, illegible writing may cause confusion or misinterpretation. Including the indication for the prescribed medication provides another safety check for the prescriber, the pharmacist, and the patient.

Refill Information This should be included on the prescription form and can be written as the number of times a prescription may be refilled or a period during which the prescription

Item Description Date of Prescription Prescriber’s Information Name and title, office or institution name, address, and telephone number, blank line

for the DEA number Patient’s Information Legal name, age or date of birth, address, weight if necessary Inscription Name of drug and strength Subscription Information for the pharmacist regarding dosage form and number of doses to dispense Signa Instructions to patients including route of administration, how often to take, special

instructions, or indication for the medication Refill Information Number of refills or length of time that the prescription may be filled Generic Substitution Indicate if a generic form is permissible or if the medication is to be dispensed as

written (DAW) Warnings What adverse effects may be caused by the medication, such as drowsiness, feeling

shaky, etc. Container Information Use of childproof containers is required unless specifically indicated to use a

non-childproof container Provider’s Signature and Title

Summary of Elements of a PrescriptionTable 9-2

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Chapter 9 Prescription Writing and Electronic Prescribing | 201

may be refilled. Most states impose a 1-year maximal refill period. Patients taking medications for chronic conditions should be assessed at least annually, so it is not prudent to write medication refills for more than a 1-year period. If the patient has prescription coverage as a benefit of an insurance plan, it is a good idea to consult the formulary for that insurance company to see whether the medication you want to prescribe is covered and whether there are regulations about how many can be dispensed in a certain period. Many companies will cover only a 1-month supply of medication at a time. It is usually of monetary benefit to the patient if he or she is prescribed a medication that is covered by the insurance plan, but that is not the only factor to consider when deciding which medication to prescribe.

Generic Substitution Most prescription forms will allow you to indicate whether the medication should be dispensed as written (DAW) or whether substitution of a generic form of the medication is permitted. Generic medications usually offer considerable cost savings to the patient, and, with few exceptions, it is preferable to allow substitution.

Warnings When you write the prescription, you should specify what, if any, warning labels should be attached to the medication package or vial. In most instances, the pharmacist filling the prescription will affix the appro- priate warnings listed in the prescribing information automatically, but you should include this information on the form. This provides another safety check between the prescriber and the pharmacist.

Container Information In many states, the law requires that pharmacists dispense medications in childproof containers. If the patient taking the medication is likely to have difficulty opening such a container (such as a patient with arthritic hands), indicate that a non-childproof container should be used.

Signature Your signature authenticates the prescription. On a prescription form, your signature should include your name and title. Signatures can be unique and may identify people, much like fingerprints, but above all they should be legible. Figure 9-2 shows a completed prescription with all the elements labeled.

Although frequently used when writing the instructions, there is controversy about whether abbreviations should be used at all. A list of commonly used abbreviations is shown in Table 9-3. Some providers and pharmacists think that writing out instructions, rather than using abbreviations, reduces the chance of a medication error.

The National Coordinating Council for Medication Error Reporting and Prevention has identified several abbreviations that are particularly dangerous because they have been misunderstood consistently. These abbrevia- tions are shown in Table 9-4. The council recommends that these should never be used in prescription writing. Refer to Appendix C for the ISMP list of Error-Prone Abbreviations, Symbols, and Dose Designations that should be avoided when writing prescriptions.

Writing Prescriptions for Controlled Medications Two main differences between noncontrolled and controlled medications are the quantity initially dis- pensed and the refills. State laws regulate the quantity of controlled medications that can be prescribed during a certain period. When indicating the quantity, write out the number instead of writing it numerically (“ten” instead of “10”), or do both. An example is shown in Figure 9-3. This helps prevent modification of the prescription. State laws also regulate the number of refills, if any, allowed for controlled substances. It is your responsibility as a prescriber to know these regulations.

MEDICOLEGAL ALERT !

According to some studies, up to 25% of ambulatory patients experience adverse medication events. Up to 6% of these adverse events could have been reduced or prevented altogether. Many preventable events involve prescribing a medication to which the patient has a known allergy. Before writing any new prescription for a patient, always ask about allergies to any medications, and prescribe accordingly. Sometimes, when asked about medication allergies, patients may describe what sounds like side effects of a medication rather than describing a true allergic reaction. If you have any doubt whether a patient is truly allergic to a medication, discuss the risk and benefits of taking the medication with the patient, and document that discussion. If the decision is made to prescribe the medication, be sure that the patient knows what signs or symptoms to be aware of and what action to take should any develop. You should always consider what medications the patient is already taking and determine the likelihood of drug interactions. Some- times, the benefit of prescribing a specific medication may outweigh the possible risk for a drug interaction or side effect; document in such a way that reflects that you are aware of possible side effects or drug inter- actions but that you believe the medication to be the most appropriate treatment for the patient’s condition.

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Common Errors in Prescription Writing According to the 2014 National Ambulatory Medical Survey, almost 77% of provider–patient encounters for acute problems result in the writing of one or more prescriptions. Serious errors can occur, both in writing the prescription and in dispensing the medication.

Several studies have identified errors commonly made in the process. These studies have shown that as many as one third of all outpatient prescriptions contain errors. Specific errors fall into these general categories: • Illegibility of any part of the prescription • Omissions: leaving off the drug name, strength,

or quantity to dispense; minor omissions include not putting the patient’s name, date, directions for use, or prescriber’s name

Figure 9-2 Prescription form showing elements.

Primary Care and Pediatric Associates

2400 Main St. Glendale, AZ 85308 Phone: 623-572-3000 Fax: 623-572-3400 David M. Wright, DO Debbie D. Sullivan, PA-C

DEA # ____________________________________________ DEA # ________________________________________

Name: ______________________________________________________________ Age: ___________________________

Address: _____________________________________________________________ Date: ___________________________

Refill ______ times Childproof Container: yes no

______________________________________________ _____________________________________________

Dispense as written Substitution permitted

8 + 11

5 + 6

7 + 10

1. Prescriber’s Information 2. Patient’s Information 3. Inscription 4. Subscription 5. Signa or Sig

6. Indication 7. Refill information 8. Generic substitution 9. Warnings (not applicable for this medication) 10. Container information 11. Signature

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Chapter 9 Prescription Writing and Electronic Prescribing | 203

Latin Abbreviation Meaning ante cibum ac before meals

bis in die bid twice a day

gutta gtt drop

hora somni hs at bedtime

oculus dexter od right eye

oculus sinister

os left eye

per os PO by mouth

post cibum pc after meals

pro re nata prn as needed

quaque 3 hora

q3h every 3 hours

quaque die qd every day

Table 9-3 Common Abbreviations Used in Prescription Writing

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It does not contain quantity information. Prescriptions should be written using the patient’s legal name, so the prescriber would need to determine if the legal name is Billy.

Electronic Prescribing In Chapter 1, we discussed several factors influencing the implementation of an electronic medical record (EMR) system as a means of delivering safe, high-quality, effi- cient, and cost-effective health care. Similarly, electronic prescribing, or “e-prescribing,” has been targeted as a key factor in preventing medical errors and reducing adverse drug events (ADEs). E-prescribing has been defined as the computer-based electronic generation, transmission, and filling of a prescription, taking the place of paper and faxed prescriptions. A more formal definition is provided in the Medicare Part D prescription drug program:

E-prescribing means the transmission, using electronic media, of prescription or prescription-related informa- tion between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network. E-prescribing includes, but is not limited to, two-way transmissions between the point of care and the dispenser.

• Dose or direction error: exceeding the recom- mended dose or substantial departure from the recommended dose; not including the indication for prn medications

• Legal requirements not met: not including the DEA number on a controlled substance prescrip- tion, dispensing a quantity above that allowed by state regulation, not spelling out the quantity of a controlled substance, including refills when not allowed by law

• Unclear quantity prescribed: quantity does not match the directions, specifying non–trade-size topical or liquid preparations

• Incomplete directions: not identifying the route, quantity to be taken at each dose, frequency of dosing

• Leading and trailing zeros: not putting a leading zero before a decimal expression of less than 1, including a trailing zero after a decimal

Seeing the actual written prescription is helpful to identify errors, as illustrated in Example 9.1.

EXAMPLE 9.1

Look at the two prescriptions shown and identify er- rors in each. Notice the tamper-resistant feature that appears as “VOID” across the paper.

The prescription for Augmentin does not include the subscription (dosage form), and there is a mismatch between number to dispense (14) and frequency and number of days to take (twice a day for 10 days = 20). The prescription for Lantus is meant to be 8 (eight) units but could easily be mistaken for 80 (eighty) units.

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204 | Guide to Clinical Documentation

Abbreviation Intended Meaning Common Error U unit Mistaken for a 0 or a 4, resulting in overdose; also mistaken for cc

when poorly written μg micrograms Mistaken for mg, resulting in overdose Q.D. Latin abbreviation for

every day The period after the Q has sometimes been mistaken for an I, and

the drug has been given qid (four times daily) rather than daily Q.O.D. Latin abbreviation for

every other day Misinterpreted as Q.D. (daily) or Q.I.D. (four times daily); if the O is

poorly written, it looks like a period or an I SC or SQ subcutaneous Mistaken as SL (sublingual) when poorly written TIW three times a week Misinterpreted as three times a day or twice a week D/C Discharge Patient’s medications have been prematurely discontinued when D/C

(intended to mean “discharge”) was misinterpreted as “discontinue” because it was followed by a list of drugs

HS half strength Misinterpreted as the Latin abbreviation HS (hour of sleep) cc cubic centimeter Mistaken as U (unit) when poorly written AU, AS, AD Latin abbreviation for both

ears, left ear, right ear Misinterpreted as the Latin abbreviation OU (both eyes), OS (left eye),

OD (right eye) IU International unit Mistaken as IV (intravenous) or 10 (ten) MS, MSO4, MgSO4 Confused for one another Can mean morphine sulfate or magnesium sulfate

Table 9-4 Dangerous Abbreviations to Avoid

Adapted from Council recommendations to enhance accuracy of prescription writing. National Coordinating Council for Medication Error Reporting and Prevention. http://www.nccmerp.org/dangerous-abbreviations. Accessed March 25, 2017.

Federal Initiatives for Electronic Prescribing Since early 2000, many federal and state organi- zations have called for the adoption of a national electronic-prescribing system. Several key federal regulations include provisions or mandates related to e-prescribing. Passage of the Medicare Modernization Act of 2003 (MMA) resulted in a significant increase in attention and focus on e-prescribing. One component of the MMA was Medicare Part D, which introduced an entitlement benefit for prescription drug coverage for Medicare beneficiaries. Under the Part D program, the MMA mandates that plans accept electronic prescriptions; it authorizes the Department of Health and Human Services to mandate transactive standards; and it provides economic incentives to prescribers for the adoption of e-prescribing. A report released by the Institute of Medicine in July 2006, Preventing Medication Errors, received widespread publicity and helped build awareness of e-prescribing’s role in enhancing patient safety. In the same year, CMS enacted three foundation standards that apply to all electronic prescribing done under Part D of the MMA. The foundation standards cover three broad areas: 1. Transactions between prescribers and dispensers

for new prescriptions, refill requests, prescription changes and/or cancellations, and related mes- saging and administrative transactions

2. Eligibility and benefits queries and responses be- tween prescribers and Part D sponsors

3. Eligibility queries between dispensers and Part D sponsors

MMA also required CMS to implement pilot projects to test additional standards related to formulary and benefit information, prior authorization, medication history, and fill status notification. These are all import- ant components of an electronic prescribing system, especially one that could be implemented nationally. In 2007, electronic prescribing became legal in all 50 states. Congress passed the Medicare Improvements for Patients and Providers Act in 2008. The act pro- vided for a 2% annual bonus for providers who started e-prescribing and penalties for those who did not. The incentive program ended in 2013.

Qualified Electronic Prescribing Similar to the “meaningful use” standard imposed on EMR adopters, criteria have also been developed for “qualified e-prescribing.” To qualify, a system must be capable of all of the following: • Generating a complete active medication list in-

corporating electronic data received from applica- ble pharmacy drug plans if available

• Selecting medications, printing prescriptions, electronically transmitting prescriptions, and con- ducting all safety checks

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Chapter 9 Prescription Writing and Electronic Prescribing | 205

• Providing information related to the availability of lower-cost, therapeutically appropriate alterna- tives (if any)

• Providing information on formulary or tiered for- mulary medications, patient eligibility, and autho- rization requirements received electronically from the patient’s drug plan

Benefits of E-Prescribing Many of the perceived benefits of e-prescribing are re- lated to decreasing medication errors and the incidence of ADEs. It is important to understand not only how e-prescribing affects patient safety but also how it affects

prescribers and their office staff, pharmacists, payers, and employers. E-prescribing provides point-of-care access to patient eligibility and formulary coverage, which helps prescribers determine the most clinically appropriate and cost-effective medication for patients. It allows for immediate access to plan formulary requirements, such as prior authorization, quantity restrictions, noncovered drugs, and drug tiers. It provides a real-time view of a patient’s medication history to all providers; because all providers see the same information, it alerts prescribers to potential drug–allergy and drug–drug interactions and decreases the chance of different prescribers giving the same medication. Access to a Clinical Decision

Figure 9-3 Controlled substance quantities.

Primary Care and Pediatric Associates

2400 Main St. Glendale, AZ 85308 Phone: 623-572-3000 Fax: 623-572-3400 David M. Wright, DO Debbie D. Sullivan, PA-C

DEA # ____________________________________________ DEA # ___________________________________________

Name: ________________________________________________________________ Age: ____________________________

Address: ______________________________________________________________ Date: ____________________________

Refill ______ times Childproof Container: yes no

__________________________________________________ _________________________________________________

Dispense as written Substitution permitted

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206 | Guide to Clinical Documentation

Support System (CDSS) helps prescribers make informed decisions about which medication is most effective.

E-prescribing brings automation of the entire pre- scribing process. New prescriptions go directly to the pharmacy’s computer, and renewal requests come back to the prescriber’s e-prescribing and EMR application for authorization. This creates a closed system that prevents prescription tampering and fraud. It also elim- inates handwritten prescriptions and errors related to illegibility and transcribing and data entry. It decreases the amount of time spent on telephone calls from dis- pensers to prescribers for queries related to illegibility, noncovered drugs, and prior authorization requirements. This allows prescribers to spend more time providing patient care and results in cost savings to pharmacies and payers. E-prescribing may also increase patient compliance because of cost-effectiveness, convenience, and a decrease in the total time it takes from generation of a prescription to dispensing of a medication.

Barriers to E-Prescribing Many of the potential barriers associated with electronic prescribing are the same as those for using an EMR system. Cost can be an issue to both prescribers and pharmacies. The pharmacy’s software vendor charges transaction fees, and there may be a one-time start-up fee and monthly charges. A free stand-alone e-prescribing system is available through the National ePrescribing Patient Safety Initiative, so prescribers may not have to purchase a system; however, they may be charged monthly access fees for certain services. Several barri- ers are related specifically to the absence of standards, certification issues, and technology. There is no standard for drug terminology or prior authorization. There is no standard for the signa, or the instructions to patients on how to take the medication. Some systems allow for free-text, whereas others use a drop-down menu, which may actually increase errors in this part of the prescrip- tion. Like EMR systems, e-prescribing systems have to meet certification criteria. Other barriers identified include software functionality problems, input errors by prescribers, inaccuracies in formulary information, and system incompatibilities that exist between prescriber software and pharmacy dispensing software.

One barrier was the inability to prescribe controlled substances electronically; however, the DEA revised a regulation that gave prescribers the option of writing prescriptions for controlled substances electronically. The Electronic Prescriptions for Controlled Substances (EPCS) rule became effective on June 1, 2010. These regulations provide the option of transmitting prescrip- tions for controlled substances electronically but do not

mandate it. They also permit pharmacies to receive, dispense, and archive these electronic prescriptions. Practitioners who wish to prescribe controlled sub- stances electronically must obtain a third-party audit or certification to certify that each electronic prescription and pharmacy application to be used to sign, transmit, or process prescriptions for controlled substances com- plies with DEA regulations pertaining to electronic prescriptions for controlled substances. E-prescribing software must be upgraded to meet standards set by the FDA. Providers must go through an identity proofing process involving two-factor authentication (TFA) credentials. DEA allows the use of two of the following: something you know (a knowledge factor), something you have (a hard token stored separately from the computer being accessed), and something you are (biometric information, such as a fingerprint screen). As of early 2017, only around 4% of prescribers nationwide were engaged in EPCS. More information on the ruling may be obtained at the DEA website: www.deadiversion.usdoj.gov/ecomm/e_rx/index.html.

The Office of the National Certification for Health Information Technology released a report in July 2014 that looked at e-prescribing trends in the United States between 2008 and 2014. In 2008, only 7% of physicians were e-prescribing using an EMR; this increased to 70% by 2014. From December 2008 to April 2014, community pharmacies enabled to accept e-prescriptions increased from 76% to 96%. In 2008, only 4% of new and renewal prescriptions were sent electronically. By 2013, 57% were sent electronically.

Summary Prescribing medications is one of the most common tasks that you will perform as a health-care provider. You have the responsibility to understand and follow federal and state laws that grant and govern prescribing authority. Avoid the use of dangerous abbreviations and pay special attention to commonly confused drugs. Because of the growing epidemic of medication misuse and overdose, ensure that you are taking steps to prevent altering of prescriptions, especially of con- trolled substances, and to safeguard prescription pads from unintended access. The adoption of electronic prescribing has demonstrated effectiveness in reducing common prescription errors and eliminating illegibility errors. To reinforce the content of this chapter, please complete the worksheets that follow. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

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Worksheet 9.1

Name:

Review

1. State two purposes of DEA registration.

2. If federal prescribing law differs from state law, which must the prescriber follow?

3. List at least two characteristics of tamper-proof prescriptions.

4. List at least five precautions that prescribers should take to control and protect their DEA registration.

5. Match the following terms and definitions.

A. signa _____ name and strength of the medication

B. inscription _____ reason the patient is to take the medication

C. subscription _____ instructions to the patient on how to take the medication

D. indication _____ medical use and abuse potential

E. schedule _____ information on dosage form and units to dispense

6. List at least five common errors made in prescription writing.

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7. List the four elements required to meet the standards for qualified e-prescribing.

8. List at least three benefits to e-prescribing.

9. List at least three barriers to e-prescribing.

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Worksheet 9.2

Name:

Medication Review I

A patient takes the following medications:

Colace 100 mg; ferrous sulfate 325 mg; aspirin 81 mg; Tramadol 50 mg

1. Look up each of the medications. Indicate which ones are available over the counter and which require a

prescription.

2. Look up ferrous sulfate. List at least three different brand names for the drug, the different preparations

available, and the strengths available.

3. Look up tramadol. List a brand name for tramadol and the name for tramadol with acetaminophen. List

the strengths available in each brand.

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Worksheet 9.3

Name:

Medication Review II

A patient takes the following medications:

Lantus 22 units each morning Lisinopril 5 mg daily

Omeprazole 40 mg daily Celebrex 200 mg daily

Xanax 0.25 mg twice daily Aspirin 81 mg daily

Boniva 150 mg monthly Mirtazapine 30 mg nightly

1. Look up all the medications listed and indicate which ones are controlled substances and on what

schedule.

2. Look up Xanax and write all the strengths that are available.

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Worksheet 9.4

Name:

Medication Review III

A patient takes the following medications:

Lotensin HCT; Mevacor; amlodipine

1. Look up Lotensin HCT. List the two medications contained in the formulation and the strengths that are

available.

2. Look up Mevacor and list the strengths that are available and the generic name for the medication.

3. Look up amlodipine on the ISMP’s list of confused drug names (available at http://www.ismp.org/Tools/

Confused-Drug-Names.aspx) and identify the drug commonly confused with amlodipine. Look up both

medications and identify why they are typically prescribed.

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Worksheet 9.5

Name:

Abbreviations

These abbreviations were used in this chapter. Beside each, write the meaning pertaining to the context of this

chapter.

ADEs

CDSS

CSA

DEA

EPCS

ISMP

NPI

TMP/SMX

CDC

CMS

DAW

EMR

FDA

MMA

TFA

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217

Admitting a Patient to the Hospital LEARNING OUTCOMES

• Identify components of an admission history and physical examination for a medical and a surgical admission.

• List specific components of typical admit orders. • Discuss the importance of medication reconciliation. • Define Computerized Physician Order Entry (CPOE) and Clinical Decision Support System (CDSS). • Discuss the benefits and challenges of using a CPOE/CDSS system. • Identify components of an admit note.

Introduction According to the 2017 American Hospital Association Annual Survey, there were about 35.1 million hospital admissions in the United States in 2015. The average length of stay for hospitalized patients was 4.8 days. Using a conservative estimate of 25 orders per patient, this amounts to 877.5 million orders generated annually. This estimate gives an indication of the enormity of the work associated with managing hospitalized patients and may help you appreciate the need for accuracy and attention to detail when authoring documents that relate to patient care.

Regulatory agencies such as The Joint Commission and the Centers for Medicare and Medicaid Services (CMS) have standards for the content of medical records for hospitalized patients. Although it is rather lengthy, CMS Section 482.24 of Title 42 from the Code of Federal Regulations (2004) deserves inclusion because it serves as the basis for much of the content of this chapter:

(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. (1) All entries must

be legible and complete, and must be authenticated and dated promptly by the person (identified by name and discipline) who is responsible for ordering, providing, or evaluating the service furnished. (i) The author of each entry must be identified and must authenticate his or her entry. (ii) Authentication may include signatures, written initials or computer entry. (2) All records must document the following, as appropriate: (i) Evidence of a physical examination, including a health history, performed no more than seven days prior to admission or within 48 hours after admission. (ii) Admitting diagnosis. (iii) Results of all consultative evaluations of the patient and appropriate findings by clinical and other staff involved in the care of the patient. (iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia. (v) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. (vi) All practitioners’ orders, nursing notes, reports of treatment, medication reports, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. (vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care. (viii) Final diagnosis with completion of medical records within 30 days following discharge.

PART III Documentation Related to Inpatient Care

Chapter 10

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218 | Guide to Clinical Documentation

Admission History and Physical Examination One of the most important documents generated during a patient’s hospital stay is the admission history and physical examination (H&P). Although CMS has regulations pertaining to when the H&P must be done, some hospitals may have different and often more stringent requirements; you are responsible for knowing and following your facility’s by-laws. Numerous members of the health-care team use information from the H&P as the cornerstone of their interactions with and management of the hospitalized patient. There are some differences between medical and surgical admis- sions. A medical admission indicates that the patient has a condition that will be managed primarily with medical therapies; pneumonia, deep vein thrombosis, sepsis, or altered mental status are examples of condi- tions that are managed medically. At times, the patient will present with a medical complaint that will require urgent or emergent and unplanned surgical interven- tion. For example, a patient who presents with acute abdominal pain may be diagnosed with appendicitis and will require an appendectomy or the diagnosis is acute cholecystitis that will require a cholecystectomy. A surgical admission is one in which the patient is admitted at a pre-arranged time to have an elective, or a planned, operative procedure to treat a specific known condition, such as a nephrectomy for renal mass, joint replacement for advanced arthritis, or surgical repair of a torn anterior cruciate ligament.

Medical Admission History and Physical Examination Gone are the days when the patient’s primary care pro- vider (PCP) admitted and followed a patient throughout the patient’s hospital stay. These duties are now assumed by hospitalists or physicians who specialize in the care of hospitalized patients. Hospitalists are usually board-certified internists, and they are responsible for coordination of care of patients and communication between members of the health-care team, including the patient’s PCP. The admitting physician is responsible for completing the admission H&P. The content of an admission H&P is much the same as a comprehensive H&P performed in an outpatient setting (see Table 2-1).

Identification Identification information will include a unique numeric or alphanumeric identifier assigned to every hospitalized patient. The terminology of such an identifier may vary, but it is often referred to as the medical record number. The same identifier is used throughout the hospital stay and is often used for the same patient for each interaction

at the hospital, whether there is an actual admission, outpatient testing, or visit to an emergency department. Policies on how to identify patients will vary from hospital to hospital; it is your responsibility to know the policy for each institution in which you have privileges.

Chief Complaint (CC) and History of Present Illness (HPI) The chief complaint (CC) should reflect the primary reason for the hospitalization and is best recorded in the patient’s own words. The same CMS Documen- tation Guidelines for Evaluation and Management (E/M) of Services discussed in Chapter 2 pertain to the admission H&P; therefore, you should document the same elements of the history of present illness (HPI). The HPI should tell the story of the patient and the symptoms that prompted the patient to come to the hospital. It is generally the longest and most detailed part of the H&P.

Past Medical History (PMH) You will see records where the HPI contains past medical history (PMH), for example “a 54-year-old man with diabetes, coronary artery disease (CAD), and hyper- tension (HTN) who presents with . . .,” but you should avoid this. The PMH is the section of the H&P used to document the patient’s ongoing medical problems and conditions that affect the patient’s overall health status. If a patient were admitted for pneumonia, it would be important to document any respiratory conditions the patient currently has or has had because the admitting problem is a respiratory system problem. Document any chronic conditions the patient is being treated for that would have an impact on the patient during the hospitalization, especially diabetes, cardiovascular disease, or cancer. Indicate if chronic problems are well controlled or uncontrolled. If the patient has had any type of surgery related to the CC, it is important to include the date and time of the surgery in the PMH; otherwise, a list of all the surgeries the patient has had in the past may not be important to document. Medication History It is always important to document all medications a patient has been taking up to the time of admission regardless of the reason for admission. Your documentation should include complete drug information, including the dosing unit, frequency of administration, and route of administration. Likewise, it is always important to document any drug allergies. In some hospitals, patients with drug allergies are given a special armband to wear that alerts all caregivers to their allergies. The chart is often flagged or marked in some way to call attention to any known allergies to avoid prescribing or admin- istering a medication that the patient is allergic to or a medication that is closely related.

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Chapter 10 Admitting a Patient to the Hospital | 219

Health Maintenance and Immunizations It is usually not necessary to document health main- tenance information in an admission H&P because the focus of the hospitalization is to treat and resolve the current medical condition, and health mainte- nance is better addressed on an outpatient basis when the patient is not acutely ill. It may be important to include immunization status if pertinent to the CC; in the case of a patient admitted for pneumonia, you should document whether the patient has had the pneumococcal vaccination and when that was given. If a patient presents with abdominal pain and weight loss, you should document if and when the patient has had a colonoscopy.

Family History (FH) The amount of family history (FH) that needs to be documented in an admission H&P will vary according to the reason for admission. If a patient is admitted for pneumonia, FH is not likely to affect management of the patient. If a patient is admitted because of acute substernal chest pain and the plan is to evaluate for myocardial infarction, a family history of cardiovascular disease would be an important risk factor that you need to be aware of because the type and number of risk factors could affect your management of the patient.

Social History (SH) It is important to document any history of tobacco, drug, or alcohol use. Patients who smoke will be at risk for specific complications related to their smoking. If a patient drinks alcohol on a daily basis, hospitalization interrupts the intake of alcohol and puts the patient at risk for withdrawal. Abrupt cessation of other sub- stances may put the patient at risk for withdrawal, so documenting the substance use alerts you to monitor for changes in the patient’s condition that may signal withdrawal. If the patient is not able to make his or her own decisions, you should document who is responsible for medical decision-making. A hospitalization can be a major stressor, not only for the patient, but also for family members. If the patient is a caregiver for someone else, such as a spouse with dementia or a child with special needs, the concern about who will care for that person often adds additional stress that can affect the patient’s course of recovery. Other SH to document includes what kind of help the patient may need at the time of discharge; what support system, if any, is available to the patient; what religious practices are important to the patient and if those practices can be observed in the hospital setting; and if there are dietary considerations that may affect the patient’s nutritional needs during the hospital stay. Ancillary personnel, such as social workers, discharge planners, nutritional counselors, and chaplains or clergy, are typically available to help

address psychosocial concerns on the patient’s behalf. At some hospitals, you may need to write a specific order to initiate these services.

Language and cultural barriers could have a dramatic impact on a patient’s hospital course. Under a number of laws (see Medicolegal Alert!), hospitals must ensure that there is no discrimination in patient care and that there is effective communication between health-care providers and patients who are deaf or hard of hearing or have any language barrier. The Office of Civil Rights (OCR) has determined that effective communication must be provided at “critical points” during the hospi- talization. Critical points include those points during which critical medical information is communicated, such as at admission, when explaining procedures, when informed consent is required for treatment, and at discharge. Many electronic medical record (EMR) systems have a specific way to document interpretive services, such as the interpreter’s name and identification number, what type of service was used (i.e., on-site interpreter or video remote interpreter), and what language was used.

MEDICOLEGAL ALERT !

The Department of Health and Human Services (HHS), Office for Civil Rights (OCR) is responsible for enforcing Title VI of the Civil Rights Act of 1964, which prohibits discrimination based on race, color, and national origin, and Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination based on disability against recipients of financial assistance from HHS. OCR is also responsible for ensuring compliance with Title II of the Americans with Disabilities Act as it applies to health and human services as well as activities of state and local governments. This legislation requires hospitals to provide interpreter services for non-English speakers or patients with other communication barriers. Using a family member or bilingual staff to interpret does not fulfill the obligation for interpreter services and can result in inaccurate information exchange that can seriously impact the patient’s health. Legislation also requires that certain forms (such as a surgical consent form) and patient education materials are available in languages other than English. Hospitals must make “reasonable accommodations” during a hospitalization to meet the needs of any person who is disabled.

Review of Systems (ROS) As a provider, you need to be aware of the CMS Guide- lines for E/M services when deciding how much of the review of systems (ROS) to document. This decision will also be influenced by the patient’s overall medical

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220 | Guide to Clinical Documentation

condition, the reason for the hospitalization, and the level of acuity. The higher the level of complexity of the E/M (see Chapter 1), the greater the need for detailed documentation. If a 25-year-old man who has no significant past medical history is hospitalized for pain related to a kidney stone, the ROS could be limited to general and genitourinary systems, and the E/M is straightforward. If a 75-year-old woman who has HTN, diabetes, hypothyroidism, and uterine cancer presents with abdominal pain, the ROS will need to be much more comprehensive, and the E/M is much more complex. At times, a patient’s condition may make it impossible to obtain any ROS (for instance, a patient on a ventilator or with advanced dementia); in such circumstances, you should always document why an ROS was not obtained.

Physical Examination General Assessment The patient’s progress—or lack thereof—will be gauged by change from his or her baseline at admission; therefore, documentation of the general assessment is important to allow for this comparison. Describe the patient’s level of alertness; orientation to person, place, and time; ability to comprehend the situation; and reliability to provide the history. If someone other than the patient provides the history, document who and his or her relationship to the patient. Describe the patient’s overall state of health, such as well-developed, well-nourished; frail and emaciated; or appears older than stated age. Documentation of the general appearance should paint a picture of the patient at the time of admission so that someone reading the H&P who has not seen the patient would be able to formulate an image of the patient. Vital Signs Multiple sets of vital signs may be documented in the admission H&P. If a patient presents to the medical floor at 15:00 and the H&P is performed at 17:00 the following day, it is appropriate to document the first set of vital signs that were obtained the afternoon of admission and then the vital signs obtained most re- cently. Document the date and time that each set was obtained. Because care is provided around the clock during a hospitalization, military time is typically used to avoid confusion between morning and evening times. In an EMR, the vital signs often autopopulate into the record, so every recorded set of vital signs is available for review.

Laboratory and Diagnostic Test Results Documentation of laboratory data and other diagnostic studies should support the need for the hospitalization. Not every test result obtained is documented in the

admission H&P because these results can be found elsewhere in the medical record. Be sure to include any results that are most pertinent to the reason for hospitalization. If you identified multiple problems in the Assessment section, then typically you would document the abnormal results correlating to each problem. Using the example of a patient admitted with pneumonia, it would be important to document that the chest x-ray confirms the presence of a right lower lobe (RLL) infiltrate, the complete blood count (CBC) shows an elevated white blood cell count (WBC) of 13.7, and the differential indicates a left shift. In most cases, normal results are not documented in this section.

Problem List, Assessments, and Differential Diagnoses Two of the most important sections of the admission H&P are those that contain the problem list, assess- ments, and differential diagnoses and that outline the treatment plan. You would list the problem that necessitated hospital admission first as the admitting diagnosis. When a patient presents with a symptom, such as chest pain, and you have not reached a definitive diagnosis, then state the problem or symptom followed by a brief overview or explanation of why the patient needs admission, as shown in Examples 10.1 and 10.2.

EXAMPLE 10.1

Chest pain, strong risk factors for cardiac etiology. Initial cardiac enzymes are within normal limits (WNL). There is ST-segment elevation in the anterior leads; however, it is unclear whether these are acute changes.

EXAMPLE 10.2

Acute mental status change. Patient transferred from long-term care facility because of confusion, hypoten- sion, and elevated WBC. Indwelling catheter in place with cloudy urine. Cultures are pending; urosepsis is a likely cause for these symptoms.

After the initial problem or diagnosis, document any significant comorbid conditions or other problems that may affect the patient’s course of treatment in the hospital. In Example 10.2 of a patient with acute mental status change, a decrease in creatinine clearance signifying renal insufficiency would be significant because renal insufficiency could affect the choice of antibiotics and could create problems with volume status. Comorbid conditions typically documented in this section include HTN, diabetes, renal disease, any hematologic or onco- logic problems, and any medical conditions that would require ongoing monitoring and treatment.

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Chapter 10 Admitting a Patient to the Hospital | 221

Plan The Plan portion of the H&P outlines what care the patient will receive during the hospitalization. It is not necessary to document every intervention that will be initiated but rather to provide an overview of treatment because you will provide details of specific treatments in the admission orders. The plan corresponding to the examples could be documented as follows:

EXAMPLE 10.3

Admit to telemetr y. Continue thrombolytic therapy that was star ted in the emergency depar tment (ED). Continue serial electrocardiograms (ECG) and cardiac enzymes. Consult cardiology.

EXAMPLE 10.4

Begin empirical broad-spectrum antibiotic therapy. Will closely monitor patient’s intake and output and daily weights. Will hold off on vasopressor therapy at this time, but it may be needed if patient becomes more hypotensive.

Procedures that will be done during the hospital- ization are documented in the Plan section sometimes, especially if more than one is needed and there could be scheduling conflicts. If the admitting physician intends to obtain consultations with specialists, this is documented in the Plan section as well. At times, the Assessment and Plan sections may be combined into one section. Examples of this are shown in some of the worksheets used in this chapter. In many EMRs, the format is determined by the system or by specific document templates. Otherwise, it is usually the personal preference of the provider to document as one section or to combine; both ways meet CMS guidelines.

Surgical Admission History and Physical Examination When a patient presents for elective surgery, the admission H&P has often been done during a pre- operative office visit with the surgeon, and then the document is transmitted to the hospital for inclusion in the patient’s medical record. Federal guidelines state that an H&P completed up to 30 days before admission is acceptable, but if it is not done within 7 days of admission, there must be documentation that the H&P was reviewed and that any changes in the interim must be documented. Advances in surgical techniques allow for many procedures that previously would have required hospitalization to be performed on an outpatient basis. Many hospitals operate out- patient or same-day surgery centers, and some may

use specially developed templates to document the admission H&P, such as the one shown in Figure 10-1. Complex surgical procedures, or procedures performed on patients with complex medical conditions, often necessitate hospital admission to ensure adequate pre-operative preparation and monitoring of the patient’s postoperative progress.

CC and HPI Your documentation of the H&P for a surgical ad- mission is similar to both a comprehensive H&P and an H&P for a medical admission; however, there are some important differences. You may state the CC as a condition (“I have gallstones”), or the patient’s state- ment may reflect what operative procedure is planned (“I am having surgery to remove my gallbladder”). The HPI documents key events or findings that indicate the need for surgical intervention.

PMH In the PMH, you should document pertinent medi- cal conditions that would affect the hospitalization. Specifically, document whether the patient has HTN, diabetes, or any condition that is being treated with corticosteroids or antiplatelet therapy because any of these will require careful perioperative manage- ment. Be sure to include a detailed surgical history, including any previous procedures, what type of an- esthesia was used, and if any complications resulted from those procedures such as bleeding, malignant hyperthermia, or anesthetic complications. Document whether the patient required transfusion of blood or blood products. As discussed previously in the medical admission H&P section, be sure to include a complete medication list and documentation of any drug allergies.

FH Your documentation of the FH should include any known bleeding disorders that are genetic or have a familial tendency. If the surgery were for a condition that has a familial predisposition, such as certain types of cancers, you would document those conditions and the family members affected as well.

SH You should document the same details of the SH dis- cussed in medical admission H&Ps in a surgical H&P. It is important to document any history of tobacco use, because this may affect respiratory function during surgery and recovery. Also document any alcohol use; if the history suggests dependence or abuse, this should alert you to monitor the patient for withdrawal symp- toms. Additionally, if there is any consideration that

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Figure 10-1 Sample same-day surgery H&P.

Central Medical SurgiCenter 1333 N. 30th St. Central City, US Phone: 802-555-4400 Fax: 802-555-4801

Same-day surgery history and physical form

Patient’s name: ___________________________________________________________ MR#: ___________________________

DOB: ___________________________________________________________________ Gender: Male Female

Diagnosis: ________________________________________________________________________________________________

Surgical procedure: _________________________________________________________________________________________

Surgeon: _________________________________________________________________________________________________

Anesthesia: General Local Other ______________________________________________________________________

Pertinent HPI: ______________________________________________________________________________________________

Medications: _______________________________________________________________________________________________

Allergies: _________________________________________________________________________________________________

Chronic medical conditions: ___________________________________________________________________________________

Pre-op labs: (check box for desired tests)

HGB HCT CBC UA ECG

CXR CMP Glucose PT INR (International Normalized Ratio)

Other: __________________________________________

Vital signs: ____ BP ____ pulse ____ resp. ____ temp

EXAM: Well developed, well nourished A&O x 3 No distress

HEENT: Normal Abnormal ______________________

Neck: Normal Abnormal ______________________

Lungs: Normal Abnormal ______________________

Heart: Normal Abnormal ______________________

Abd: Normal Abnormal ______________________

Ext: Normal Abnormal ______________________

Neuro: Normal Abnormal ______________________

Cleared for surgery? Yes No

Consent to read: _________________________________________________________________

Consent signed? Yes No NPO? Yes No

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a blood transfusion or administration of other blood products might be needed during hospitalization, be sure to identify any factor that would affect the patient’s willingness to receive such products. This is commonly seen when a patient is of the Jehovah’s Witness faith and is not willing to accept transfusion of blood or blood products.

ROS If not fully explored in the HPI, the ROS should focus on the system most closely related to the planned surgical procedure. In the example of a patient being admitted for cholecystectomy, you would document a detailed gastrointestinal ROS. Inclusion of other systems or the level of review of other systems will be influenced by the complexity of the planned procedure as well as the type of anesthesia planned and any comorbid conditions the patient may have.

Physical Examination Documentation of the physical examination should clearly establish the patient’s baseline pre-operative condition because postoperative assessment will focus on return to pre-operative functioning. Give careful attention to examination of the body area involved in the surgery. Many surgeries will be done after administration of general anesthesia; therefore, it is especially important to document pulmonary function. Examination of the upper respiratory sys- tem should include the oropharynx, noting any loose teeth or dental work, such as partial or full dentures. Lower respiratory system assessment should include chest shape, symmetry of expansion with respiration, diaphragmatic movement, respiratory effort, and the quality of breath sounds in all lung fields. How much additional examination is done is influenced by the presence of comorbid conditions, overall patient health status, complexity of the planned surgical procedure, estimated operative time, and anticipated postoper- ative course.

Laboratory and Diagnostic Test Results Laboratory and other diagnostic studies are sometimes completed on an outpatient basis before the patient’s hospital admission. When this is the case, it is important to document pertinent results in the H&P, and a copy of all results should be made part of the permanent medical record. The need for baseline pre-operative testing is correlated to the patient’s age, overall medical condition, and type of surgery the patient will have. Some facilities have set policies, such as obtaining an ECG in every patient 40 years of age or older and a chest x-ray (CXR) in any patient who smokes or who is 50 years of age or older.

Problem List, Assessments, and Differential Diagnoses and the Treatment Plan Typically, you would list the condition necessitating surgical intervention first in the Assessment and prob- lem list section, followed by any comorbid conditions that would require perioperative monitoring or that could potentially give rise to postoperative complica- tions. Documentation of the Plan section includes the planned operative intervention and may also include specific pre-operative preparation, patient education, consultations, and a general outline of postoperative care.

Sample H&P Chapter 2 contains a sample comprehensive H&P for Mr. William R. Jensen (see Fig. 2-2) who presented in an outpatient setting to Dr. Scott and was evaluated for fatigue and blood in the stool. Subsequent evaluation by a gastroenterologist and surgeon led to the diagnosis of adenocarcinoma of the colon. Using a case study format, we will follow this patient’s care as he is admitted for surgical management. Figure 10-2 shows a sample admission H&P for Mr. Jensen when he presents for surgical management. Compare Figures 10-2 and 2-2 to see how the comprehensive H&P is modified for a surgical admission H&P.

Two sets of admit orders will be written for Mr. Jensen: his initial pre-operative admit orders and the initial postoperative orders. We discuss documentation of an admit note in this chapter. In Chapter 11, we will follow Mr. Jensen’s care through documentation of the operative report, an operative note, daily progress notes, and orders, and then conclude the hospitalization with documentation of discharge orders and the discharge summary in Chapter 12.

Admission Orders When a patient is admitted to the hospital, the orders written at the time of admission direct the health-care team in caring for the patient. It is important that the orders are completed in a timely manner and are unambiguous. Once written, an order is in effect until another order is written to change or stop the original order, unless a time or dose limit is provided in the original order. For example, an order to record intake and output would be carried out until an order is written to discontinue recording intake and output. An order for Ancef 1 g IV every 8 hr × 3 doses will be given for only 3 doses; thus, it is not necessary to write an order to stop Ancef. However, an order for heparin 5,000 units SQ every 8 hours would be given every day that the patient is in the hospital unless the order is specifically discontinued.

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Mr. Jensen’s Admission History and Physical Examination

PATIENT NAME: William R. Jensen ADMIT DATE: XX/XX/XX

SEX: Male Billing #: 5728431

DOB: XX/XX/XX MEDICAL RECORD #: 35-87-26

Dictating Physician/PA/NP: Sanders, David K., MD

Primary Care Physician: Vernon Scott, MD

CHIEF COMPLAINT: “I have cancer, and I’m going to have surgery.”

HISTORY OF PRESENT ILLNESS: This is a 67-year-old Caucasian male who was referred to me by his primary care physician, Vernon Scott, MD, after being diagnosed with colon cancer. Mr. Jensen initially presented to Dr. Scott’s office with complaints of fatigue and “feeling weak.” During a routine workup, he was found to have hemoccult-positive stool. At this time, Mr. Jensen was referred to a gastroenterologist, Michael Bennett, MD. Dr. Bennett performed a colonoscopy on Mr. Jensen and found several suspicious polypoid lesions at the right hepatic flexure area. Biopsies were obtained and sent to pathology. Pathology reports confirm adenocarcinoma. Dr. Scott and Dr. Bennett consulted, and they referred Mr. Jensen to me for surgical evaluation. I saw Mr. Jensen in my office on XX/XX/XX and discussed with him options for treatment. I recommended that we proceed with a right hemicolectomy. I discussed with Mr. Jensen and his wife the likely benefits of the surgery. I discussed specific risks of surgery, including infection, bleeding, perforation of bowel or vessel, possible anesthetic complications, and death. I answered questions to their satisfaction and believe Mr. Jensen competent to give informed consent. He stated his wish to proceed, and his wife is agreeable; therefore, Mr. Jensen is admitted now for elective surgery.

PAST MEDICAL HISTORY: Medical: Mr. Jensen has a history of hypertension, dyslipidemia, and left inguinal hernia. Hypertension and dyslipidemia are medically managed by Dr. Scott and are stable at this time.

Surgical: Mr. Jensen had repair of a torn rotator cuff, right shoulder (Dr. Rodriquez, Grand Rapids, MI), approximately 24 years ago. He had a left inguinal herniorrhaphy approximately 15 years ago (Dr. Simmons, Grand Rapids, MI). All surgical procedures tolerated well; no complications with bleeding or infection postoperatively. He did not have any complications from anesthesia. He has never had any blood transfusions but is agreeable to receive blood or blood products if needed. Since the likelihood of significant bleeding is fairly low, he did not arrange for autologous donation.

Medications: Lotensin HTC 20/12.5, once daily; Mevacor 20 mg once daily. Occasional acetaminophen.

Allergies: Mr. Jensen states an allergy to PENICILLIN DRUGS and breaks out in a rash when he takes anything containing penicillin.

FAMILY HISTORY: Mother deceased, age 70, breast cancer. No other family history of cancer. No history of bleeding disorders.

SOCIAL HISTORY: Mr. Jensen is a retired electrician. He is married and lives in a single-story home with his wife. They have three adult children who all live nearby. Mr. Jensen smokes a pipe about 3 times a week. He does not drink alcohol or use any recreational drugs. He is still active and walks approximately 2 miles 4 of 7 days per week. He also bicycles occasionally. He is competent to make his own decisions regarding health care. He has designated his wife as medical power of attorney. Advance directives and living will have been discussed, and both were present at time of admission. Mr. Jensen desires full resuscitation and any heroic measures indicated. His wife and children are available to help care for him at home after discharge. They have a good support system. He denies any specific dietary considerations. No particular religious practices that he desires to participate in while in the hospital.

REVIEW OF SYSTEMS: General: Easily fatigued, feels weak. Denies any near-syncope or lightheadedness. Overall mood is positive, and he believes having the surgery is his best chance for cure.

HEENT: Denies previous nasal or sinus surgery. Denies dental problems.

Respiratory: Denies cough or shortness of breath.

Cardiovascular: Specifically denies chest pain, angina, and pleuritic pain. Denies any heart palpitations or irregularities in rhythm. No history of heart murmur.

Gastrointestinal: Biopsy-proven adenocarcinoma per HPI. Hemoccult-positive stool at initial presentation to Dr. Scott, along with 10-pound unintentional weight loss over past few months. Weight has been stable since. Denies abdominal pain, nausea, vomiting, diarrhea. Denies any difficulty swallowing or chewing. Genitourinary: Denies nocturia or dysuria.

Hematologic: Denies easy bruising or bleeding from gums.

(Continued)

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Chapter 10 Admitting a Patient to the Hospital | 225

Figure 10-2 Mr. Jensen’s admission H&P.

PHYSICAL EXAMINATION: Vital Signs: BP 142/80; P 86 and regular, R 16 and regular; Temp 97.8 orally. His current weight is 174 pounds.

General: Mr. Jensen is a well-developed, well-nourished Caucasian man who is alert and cooperative. He is a good historian and answers questions appropriately.

Skin: Intact, no lesions noted. Turgor is good.

HEENT: Nose patent bilaterally. No polyps noted. Oropharynx without erythema or exudate. Buccal mucosa intact without lesions. Full dentition in good repair, no loose teeth.

Neck: No carotid bruits. No tracheal deviation noted. No masses palpated.

Cardiovascular: Regular heart rate and rhythm. No murmurs, gallops, or rubs.

Respiratory: Breath sounds clear to auscultation in all lung fields. Diaphragmatic excursion is symmetrical. No increased AP diameter.

Abdomen: Soft, nontender. No masses or organomegaly. Bowel sounds physiological in all four quadrants. No guarding or rebound noted. Well-healed left inguinal scar from previous surgery.

Rectal/GU: Soft brown stool in rectal vault, guaiac positive.

Musculoskeletal: No clubbing, cyanosis, or edema.

Neurological: CN II–XII grossly intact. No focal neurological deficits.

LABORATORY DATA: CBC: WBC 5,800; Hct 48; Hgb 16. Peripheral smear shows normochromic, normocytic cells, differential unremarkable.

CXR: No consolidations or effusions.

UA: WNL.

PT, PTT (partial thromboplastin time): 12.4 and 31. ECG: Normal sinus rhythm with rate of 84. No ectopy, no ischemic changes.

ASSESSMENT: 1. Adenocarcinoma of the colon. 2. Hypertension. Stable on current medications. Will be monitored closely postoperatively. 3. Dyslipidemia.

PLAN: 1. Mr. Jensen is admitted for elective right hemicolectomy. Admission orders written. Consent form completed and on chart. 2. Routine postoperative care. 3. Will have Dr. Scott follow for medical management of hypertension.

David K. Sanders, MD

DD: XX/XX/XX 0927

DT: XX/XX/XX 1132

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At some facilities, it is acceptable to use precompleted order sets. These order sets are developed for conditions that require hospital admission so often that the same orders would be written over and over, such as chest pain, rule out acute myocardial infarction (AMI); cerebrovascular accident (CVA); or pre-operative care. In facilities where precompleted orders are used, there is usually an estab- lished protocol for development, review, and acceptance

of the order sets that involves medical staff members from various disciplines, nursing staff, pharmacists, and sometimes other health-care team members. An example of a precompleted order set is shown in Figure 10-3. In facilities that use EMR, usually you will be able to create your own order sets. There are several mnemonics that may be used to help you remember what should be included in admission orders. One mnemonic is AD

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Figure 10-3 Pre-operative order set.

Pre-admission Orders

Tests:

Pre-admission Labs: ____________________________________________________________________________________ ______________________________________________________________________________________________________

Other Tests:

______________________________________________________ Medical Necessity _______________________________

Orders are per anesthesia guidelines

RN Sign/RN Initials Date Time

Pre-operative Orders

Start Intravenous (IV) Fluid _____________________________________ 1,000 mL at to keep open rate.

May use lidocaine/prilocaine (Emla) Cream for IV site discomfort

May use Pain Ease for IV site discomfort

Lidocaine 1%: give 0.1 mL intradermal for IV site prep.

Other IV: _____________________________________________________________________________________________

Tests:

Pre-operative Labs: _______________________________________________________________________________________ _______________________________________________________________________________________________________

Other Tests: ______________________________________________________ Medical Necessity _______________________________

______________________________________________________ Medical Necessity _______________________________

Treatments:

Arterial Line:

Small-volume nebulizer orders: __________________________________________________________________________

Additional Orders: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________

Physician Name - Print and Sign Date Time

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CAVA DIMPLS, which stands for Admit, Diagnosis, Condition, Activity, Vital signs, Allergies, Diet, Inter- ventions, Medications, Procedures, Labs, and Special instructions. Each component is described in more detail and an example of each is provided. Figure 10-4 presents the mnemonic in a condensed form.

Admit Specify the admitting physician and the hospital unit to which the patient should be admitted. Admit to Dr. Johnson to the orthopedic floor or Admit to Dr. Myers to telemetry unit.

Diagnosis State the admitting diagnosis and, in the case of a surgical admission, include the name of the procedure to be performed. When a patient has more than one admitting diagnosis, be sure to list the problem most responsible for admission as the primary diagnosis. If there are any comorbid conditions that should be monitored during the hospital stay, document them as additional diagnoses. Primary diagnosis: pneumonia. Secondary diagnosis: type 2 diabetes.

Condition This reflects the patient’s condition at the time of admission based on overall appearance, vital signs, and severity of injury or illness. If a patient has multiple injuries from a motor vehicle crash and is semicon- scious with unstable vital signs, the condition might be

documented as critical. If a patient is having crushing chest pain and is diaphoretic with an irregular heart rate, the condition might be documented as unstable. Other words commonly used to describe condition are stable, guarded, moribund, and comatose.

Activity Indicate the level of activity the patient is permitted to have. There are several activity orders commonly used; the condition of the patient (including mental alertness) and the overall health condition of the patient determine which order is most appropriate. Common activity orders include the following:

• Up ad lib (the patient may be out of bed as he or she wishes)

• Activity as tolerated (whatever the condition allows the patient to do)

• Bedrest with bathroom privileges, abbreviated as BR with BRP (allowed out of bed to go to the bathroom; otherwise in bed)

• Out of bed (OOB) • Ambulate a certain number of times a day • Ambulate with assistance • Non–weight-bearing

Vital Signs This order reflects how often the standard vital signs (VS) (temperature [T], heart rate [HR], respiratory rate [RR], and blood pressure [BP]) should be obtained

Figure 10-4 Admission orders mnemonic.

AD CAVA DIMPLS

Admit: admitting physician and type of unit or hospital floor

Diagnosis: chief reason for the patient’s admission

Condition: usually a one-word description

Activity: level of activity allowed depending on age, diagnosis, medications, etc.

Vital signs: frequency with which vital signs should be obtained

Allergies: list any medication allergies

Diet: what type of diet the patient is allowed

Interventions: IV therapy, respiratory therapy, etc.

Medications: medications related to reason for admission and any chronic medications the patient may be taking

Procedures: wound care, ostomy care, etc.

Labs: any laboratory or diagnostic tests needed

Special instructions: notify if certain parameters are exceeded, or conditional orders (if this occurs, do this)

Admission Orders Mnemonic

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and will vary according to the patient’s condition. Some hospitals have standing orders for VS depending on the type of unit or floor to which the patient is admitted. Critical or intensive care units almost always have their own standing orders. Some VS are monitored continuously as the patient’s condition warrants; for instance, BP and HR are monitored continuously in a patient who recently had a myocardial infarction. Typical orders for medical admissions are VS q8h while awake (if the patient is very stable and if it is not necessary to awaken a patient to obtain VS) and VS q4h.

Generally, weight is obtained only at the time of admission. If a patient’s condition necessitates moni- toring of volume status or renal function as in the case of heart failure, edema, or fluid retention, write an order to weigh daily.

Allergies This is not actually an order but rather a specific no- tation of allergies that the patient may have to any medication, food, or other substance. It is customary to include the specific agent the patient is allergic to and what reaction the patient has to the agent. One way to note this is Allergic to penicillin (rash) and aspi- rin (dyspnea). You may find some providers document the details of the reaction in the PMH section of the admission H&P and list the drugs only in the orders; this is an acceptable practice. If it is hospital policy to identify patients with allergies by a special armband or other designation, then it is not necessary to write a specific order for this.

Diet The first step in deciding what type of diet to order is usually to determine whether it is safe to allow the patient to eat. If the patient is going to have surgery or a procedure that requires sedation and, therefore, car- ries a risk for aspiration, or if a patient is not mentally alert enough or physically able to eat and swallow, it is safer for the patient not to receive any nourishment by mouth. The order for this is NPO, an abbreviation for the Latin phrase nil per os, interpreted as nothing

by mouth. If allowing the patient to eat does not pose a threat to safety, there are many dietary orders that you can write. It is not possible to include all the dietary orders in this text; some of the more common types of diets are shown in Table 10-1. Consultation with a dietitian is usually an option. Often hospitals will have a dietary manual available for review as well.

Interventions This refers to interventions by nursing or other ancillary staff, such as physical therapy or respiratory therapy. One example of an intervention is single volume nebulizer (SVN) with 0.5 mL albuterol in 2.5 mL normal saline (NS) q4h. Another example is Physical therapy (PT) to evaluate and treat. Intravenous (IV) therapy is also considered an intervention. If you write an order for IV therapy, you should specify the type of fluid and the rate of administration, such as D5NS (5% dextrose in NS) at 80 mL/hr. (Consult the Bibliography for suggested readings related to principles of IV therapy.)

Medications Unfortunately, medication errors and adverse drug events are common during a hospitalization. The impact of these events on patient welfare and the financial burden, both to the patient and the health-care system, are significant. In 2005, The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No. 8 in an effort to minimize adverse events at point of care transitions. Medication reconciliation is the process of comparing a patient’s medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors, such as omissions, duplica- tions, dosing errors, or drug interactions. This process comprises five steps: 1. Develop a list of current medications (includ-

ing prescription medications, over-the-counter medications, herbals, vitamins, and nutritional supplements).

2. Develop a list of medications to be prescribed.

Condition Dietary Intervention Typical Order Diabetes Restrict sugars and fats; follow

recommendations of the American Diabetes Association

45 grams carbohydrate 60 grams carbohydrate

Hypertension, kidney disease Salt restriction Low-sodium diet, 2 g Na+ diet Coronary artery disease or

hypercholesterolemia Fat and cholesterol restriction Cardiac diet; heart healthy diet; low-fat, low-

cholesterol diet, National Cholesterol Education Program Step Two diet

Unable to chew well, ill- fitting dentures

Allow soft foods only Soft mechanical diet

Table 10-1 Common Diets for Oral Intake

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3. Compare the medications on the two lists. 4. Make clinical decisions based on the comparison. 5. Communicate the new list to the patient and to

appropriate caregivers. Because additional medications are likely to be pre- scribed during the hospitalization, you must complete a thorough medication reconciliation at the time of admission so you and the pharmacy staff can determine whether drug–drug interactions or drug–disease inter- actions could occur. With that in mind, always specify the name of the medication, the dose, the route, and frequency of administration (see Chapter 9, Elements of a Prescription section). It is common to write orders first for any medications that are given for the condi- tion necessitating hospitalization, then orders for any medications taken before hospitalization that need to be continued, and then orders for any symptomatic medications.

Symptomatic medications are those that may or may not be needed. During a hospitalization, patients experience sleeplessness, constipation, pain, and nausea with such frequency that typically orders are written at the time of admission so that medications are available to treat these symptoms if they develop. Not only will these orders reduce discomfort for the patient, they will also prevent nursing staff from having to call you at 2:00 to request a sleep aid. You would order these medications on an as-needed (or PRN, Latin for pro re nata) basis, and they would be administered only as requested by the patient. If you write an order for a PRN medication, you always want to include the indication for giving the medication. An order written as morphine 2 mg IV PRN is open for interpretation. Although the nursing staff would recognize that morphine is a narcotic analgesic and would know that it is given to relieve pain, the order is ambiguous. Instead, it should be written with specific dosing, frequency, and indication instructions, such as morphine 2 mg IV q2h PRN mild pain. This prevents the medication from being administered for reasons other than pain and establishes a safe time frame in which the medication may be administered. Always order a specific dose, rather than a range of dosing such as morphine 2–6 mg IV q2-3h PRN pain. This helps prevent inappropriate administration of the medication.

Procedures Many routine procedures are part of a patient’s daily care, and it may seem intuitive that these procedures should be performed. However, writing an order for such procedures as daily catheter care, wound or ostomy care, and dressing changes provides justification for performing these procedures and allows the hospital to charge for the necessary supplies. The order should specify how frequently the procedures should be carried out, such as dressing change three times daily.

Laboratory and Other Diagnostic Studies It may be necessary to monitor certain laboratory values or obtain diagnostic studies as part of a patient’s care. For instance, when a patient is on an anticoagulant medication, you monitor the bleeding time. If a patient develops fever and a cough, you might order a CXR. You should always have a rationale for ordering laboratory or other diagnostic studies. If a patient had surgery but had very little intra-operative bleeding, it is unnecessary to order H&H (hematocrit and hemoglobin) q am; you would not expect the values to change because there was little blood loss. When ordering imaging studies such as x-rays or computed tomography (CT), you should include the indication for the study, not only to aid in the interpretation of the study but also to establish the relevance of the study to the patient’s overall care. An example is AP (anteroposterior) & lateral CXR to evaluate for pneumonia.

Special Instructions The rationale for special instruction orders is to ensure that nursing staff informs you of changes in a patient’s condition that may require some intervention. For instance, results of glucose monitoring above or below a certain level may require withholding, increasing, or decreasing insulin doses. You would write an order to Notify Dr. Wattanapanit if blood sugar is less than 100 mg/dL or greater than 350 mg/dL. If a patient was admitted two days ago for AMI and now has new onset of atrial fibrillation, you want to be alerted to that fact. You should never assume that the nursing staff will notify you automatically of such developments. As a general rule, they probably would; however, the responsibility of managing changes in the patient’s condition rests on the attending medical staff—not the nursing staff—and you can manage only what you are aware of. Writing the special instruction order protects you as a clinician and helps to ensure the best treatment for the patient.

Perioperative Orders Perioperative is a term that is used to refer to all three phases of surgery (pre-operative, intra-operative, and postoperative). When a patient is admitted for sur- gery, the initial pre-operative orders are in effect until the patient goes to surgery. Pre-operative orders for Mr. Jensen are shown in Figure 10-5. After surgery, the patient goes to the postanesthesia care unit (PACU), sometimes referred to as the recovery room. While the patient is there, the staff generally follows prewritten PACU orders, like those shown in Figure 10-6. Once the patient is awake, maintaining an airway with adequate respirations and has stable vital signs, the patient is essentially re-admitted to the hospital and a new set of

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Figure 10-5 Pre-operative admit orders for Mr. Jensen.

Pre-operative Admission Orders for Mr. Jensen

XX/XX/XX 2030

1. Admit to Dr. Sanders, surgical floor

2. Dx: colon cancer

3. Condition: good

4. Activity: up ad lib

5. Vital signs q4h while awake

6. Allergic to PENICILLIN

7. Clear liquid diet now; NPO after midnight

8. Instruct on use of incentive spirometry

9. IV D5NS at 80 mL/hr

10. Restoril 15 mg at bedtime prn for sleeplessness

11. Valium 5 mg IM on call to operating room

12. Hold routine meds at present

Signature, title: _______________________________________________

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postoperative orders must be written. We use the same mnemonic provided earlier, AD CAVA DIMPLS, to write the postoperative orders for Mr. Jensen.

Admit The patient is typically admitted to the surgeon.

Diagnosis The postoperative admitting diagnosis is usually the condition that required surgical intervention, and it may include the type of procedure done. For instance, Mr. Jensen’s admitting diagnosis could be written as colon cancer, status post (S/P) hemicolectomy.

Condition Condition refers to how the patient is doing immediately after surgery when the postoperative orders are written.

Activity When writing the activity order, keep in mind that postoperative patients usually require at least some narcotic pain relief, which may impair judgment or function. Safety precautions may be indicated, such as side rails up at all times or ambulate only with assistance. To prevent complications associated with immobility, patients are encouraged to be out of bed immediately

after surgery, but you must take into consideration the type of surgery and the patient’s overall condition when determining the activity level. An activity order for Mr. Jensen could be OOB three times a day (TID) with assistance.

Vital Signs In the immediate postoperative period, vital signs are obtained progressively. A common postoperative order is VS qh x 4; if stable, then q2h x 4, then q4h. An order such as this reflects the possibility that a patient’s condition might change in the immediate postoperative period and that more frequent assessment is needed initially, but if the patient’s vital signs remain stable, then less frequent assessment is permitted.

Allergies Any allergies should be noted in the orders.

Diet Surgical patients usually have special dietary needs in the postoperative periods. The type of surgery and the type of anesthesia usually determine the type of diet ordered. When a patient undergoes surgery involving the gastrointestinal tract, often paralyzing agents are used to prevent peristalsis during surgery. Various factors

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Chapter 10 Admitting a Patient to the Hospital | 231

Figure 10-6 PACU orders.

Oxygen 2–6 L with nasal cannula or 6–10 L/min flow with simple mask. Titrate to maintain saturation above 93%. Small-Volume Nebulizer - __________________________ for bronchospasm. Remove oropharyngeal / nasopharyngeal airway when patient maintains airway. May reinsert as needed for airway obstruction.

Hypotension for Blood Pressure less than _______ systolic Call Anesthesia

Ephedrine _______ mg IV every _______ minutes 5% Albumin 250 mL IV over _______ minutes Fluid Bolus 500 mL Ringer’s Lactate IV over 30 minutes Other: _________________________________

Sinus Bradycardia: defined as heart rate below 40 Atropine 0.5 mg IV every 5 minutes until a heart rate greater than or equal to 60 or a maximum dose 3 mg is achieved. Call Anesthesia CAUTION: Doses less than 0.5 may be associated with paradoxical bradycardia.

Other: ____________________________________________

Hypertension for Blood Pressure greater than _______ systolic Call Anesthesia

PREFERRED AGENTS FOR SAME-DAY SURGERY (SDS) PREFERRED AGENTS FOR INPATIENT USE Esmolol (Brevibloc): Give 500 mcg/kg IV over 1 min. if Labetalol (Trandate) 5 mg IV every 5 minutes. Maximum 20 inadequate response, give 50 mcg/kg IV—repeat every minute mg IV. as needed for hypertension and/or tachycardia. Maximum of 4 Do NOT give if heart rate less than ___________ doses. Do NOT give if heart rate less than _____________

Medications: Hold and Notify Physician of Allergy to Any Ordered Medication

Morphine sulfate: 2 mg IV every 5 minutes for moderate pain (pain scale 4–7) 2 mg IV every 2 minutes for severe pain (pain scale 8–10); MAX DOSE: _______ mg Hydromorphone: 0.2 mg slow IV push every 5 minutes for moderate pain (pain scale 4–7) 0.2 mg slow IV push every 2 minutes for severe pain (pain scale 8–10); MAX DOSE: _______ mg Fentanyl: _______ mcg IV every 5 minutes for moderate pain (pain scale 4–7) _______ mcg IV every 2 minutes for severe pain (pain scale 8–10); MAX DOSE: _______ mg Ketorolac: _______ mg IV one time for moderate pain; do not use with moderate renal impairment Acetaminophen 325 mg: 2 tablets orally for mild pain (scale 1–4) every 4 hours as needed. Hydrocodone/Acetaminophen 5 mg/500 mg: 1 tablet orally as needed every 4 hours for moderate pain (pain scale 5–7) 2 tablets orally as needed every 4 hours for severe pain (pain scale 8–10) Oxycodone/Acetaminophen 5 mg/325 mg: 1 tablet orally as needed every 4 hours for moderate pain (pain scale 5–7) 2 tablets orally as needed every 4 hours for severe pain (pain scale 8–10)

Midazolam: _______ mg IV as needed for anxiety; MAX DOSE: _______ mg Lorazepam: _______ mg IV as needed for anxiety; MAY REPEAT _______ times

Droperidol: 0.625 mg IV every 15 minutes for nausea; maximum dose of 1.25 mg in 1 hour. Ondansetron: 4 mg slow IV push over 2 minutes for nausea; to be given as a one-time dose only on the day of surgery Prochlorperazine: 5 mg slow IV push over 2 minutes every 6 hours as needed for nausea; may repeat dose after 15 minutes if no relief. Maximum dose of 10 mg in 6 hours. Total maximum dose in 24 hours is 40 mg. Metoclopramide: 10 mg IV one time for nausea

Meperidine: 12.5 mg slow IV; push every 15 minutes as needed for treatment of postanesthetic shivering; MAX DOSE: _______ mg

Oral Agent: _________________________________________ Oral Agent: ____________________________________

Other: _____________________________________________ Other: ________________________________________

Other:

Fingerstick for glucose as needed

Other: _______________________________________________________________________________________________

Discharge when criteria of Aldrete score greater than or equal to 8 is met or per physician order.

Physician Name - Print and Sign - To Activate Only Orders Checked Above Date Time

** DISCONTINUE MEDICATION ORDERS ON THIS PAGE WHEN TRANSFERRED TO NURSING UNIT **

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such as age, mobility, and overall health status affect how quickly bowel function returns after surgery. Patients are often kept NPO until bowel function returns. Once bowel function resumes, indicated by the return of bowel sounds or passing of flatus, you can advance the patient’s diet from liquids to solids as tolerated. Typically, the initial diet order is clear liquids. If the patient is able to tolerate clear liquids without any nausea or vomiting, then the diet is advanced to full liquids and then to a regular diet or any special diet indicated for specific medical conditions. Table 10-2 provides information about the liquids and foods allowed on clear and full

liquid, soft, and regular diets. You may find that some practitioners prefer to write an order to advance diet as tolerated and not specify when to advance the diet or what type of diet to follow, leaving the details to the judgment of the nursing or dietary staff.

Interventions Like any patient who has had abdominal surgery, Mr. Jensen is likely to have shallow respirations post- operatively, which puts him at risk for pulmonary complications. To prevent such complications, an important intervention order for Mr. Jensen is incentive spirometry (IS) 10 times per hour while awake. Another important intervention is maintaining hydration and nutrition. Until adequate oral intake is possible, IV fluids should be administered. For Mr. Jensen, we will order D5NS @ 120 mL/hr.

Medications Mr. Jensen will require some medications. Medications administered orally may be withheld until bowel func- tion returns. Symptomatic medications are indicated, especially for pain and nausea. Specify not only the name of the medication but also the dose, route, and frequency and the indications for any PRN medications. Some hospitals require the use of generic drug names, whereas others accept generic or trade names. Check with the hospital pharmacy to be sure which you should use. A common option for managing postoperative pain is a patient-controlled analgesia (PCA) system. This refers to an electronically controlled infusion pump that delivers a prescribed amount of IV analgesic to a patient when the pump is activated. Use of PCA has been shown to reduce the time between when a patient feels pain and when the analgesia is delivered. It also reduces the chances for medication errors because the PCA is programmed per the physician’s order for specific doses and time intervals between doses. There is also a “lock-out” feature that prevents overdosing. Figure 10-7 shows an order set for PCA.

An anti-emetic drug is usually ordered as a PRN medication. Nausea is common in the postoperative period, and anti-emetics can reduce nausea and prevent vomiting. Most anti-emetics potentiate the action of narcotic analgesics, so frequently they are administered together. However, you would order the analgesics and anti-emetics separately so that they may be administered individually if both are not needed.

Once bowel function returns, Mr. Jensen’s pre-operative medications should be restarted. It is also desirable to change from parenteral to oral analgesics when the patient can tolerate oral intake. In fact, the patient’s ability to obtain effective pain relief from oral analgesics and return to oral intake of liquids and foods is often considered criteria for discharge.

Type of Diet Foods Allowed Clear Liquid Diet Often prescribed

for a short period after surgery to give gastrointestinal tract a rest

Broth Gelatin Tea Popsicles Clear juices, such as apple,

cranberry, or grape Clear sodas, such as lemon-lime

or ginger ale Coffee may be allowed with

physician approval Full Liquid Diet Prescribed as a

transition from clear liquid to a soft or regular diet

All the foods shown for clear liquid diet plus:

Milk Yogurt Pudding Milkshake, ice cream, sherbet Smooth cream soups Oatmeal, cream of wheat, grits,

gravy Dark sodas, such as colas Juices with pulp, such as orange,

grapefruit, pineapple Soft Diet May be prescribed if

patient has a sore throat following endotracheal intubation or dental problems

Oatmeal Mashed or baked potatoes Bananas Scrambled eggs Soft bread or rolls (not toasted) Applesauce Gelatin Puddings

Regular Diet Similar to what most

patients would consume at home

Most foods are allowed; moderate in salt, sugar, and fat

Specific foods not allowed will vary by facility; consult with dietary and nutritional support personnel

Table 10-2 Diets Commonly Used in the Postoperative Period

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Figure 10-7 PCA order set.

______ mg (1–2.5 mg [1 mg*]) ______ mg (0.2–0.4 mg [0.2 mg*]) ______ mcg (10–25 mcg [10 mcg*])

_____ mg (2–4 mg) IV every 15 ______ mg (0.2–0.6 mg) IV every 15 ______ mcg (10–40 mcg) minutes until patient comfortable. minutes until patient comfortable. IV every 15 minutes until Not to exceed 3 doses. Not to exceed 3 doses. patient comfortable. Not to exceed 3 doses.

When patient begins to use oral pain medication, increase lockout to ______ minutes. Continuous pulse oximetry, except when ambulating. Nasal oxygen administration: 1–4 liters as needed to maintain oxygen saturation greater than or equal to ______ %. Contact physician for oxygen saturation less than ______ %. Other: _______________________________________________________________________________________________ Notify physician for: • Respiratory rate less than 8 per minute AND initiate naloxone (Narcan) protocol. • Uncontrolled pain • Persistent itching

ADULT PATIENT-CONTROLLED ANALGESIC (PCA) ORDER FORM

Contact the following physician for orders, questions, or inadequate pain relief: ________________________________________

Choose one item Morphine Sulfate 1 mg/mL HYDROmorphone 0.2 mg/mL Fentanyl 20 mcg/mL

______ min (6–15 min [12 min*]) ______ min (6–15 min [8 min*]) ______ min (4–8 min [6 min*])

Loading Dose

PCA Demand Dose

Lockout Interval

Ranges marked with * are recommended for opioid-naive patientsRanges marked with * are recommended for opioid-naive patients

Bolus Dose

4-hour Limit ______ mg (15–30 mg) ______ mg (4–8 mg) ______ mcg (100–200 mcg)

______ mg every ______ hours ______ mg every ______ hours ______ mcg every ______ hours

______ mg/hr (0–2 mg/hr [1 mg/ ______ mg/hr (0–0.3 mg/hr [0.2 mg/ ______ mcg/hr (0–25 mcg/ hr*]) hr*]) hr [10 mcg/hr*])

Restricted to opioid-tolerant patients Basal Rate (optional)

Doses shown in parentheses are for reference only—patient’s needs may require more or less than shown

Supplemental PCA administration instructions:

If no continuous IVF ordered, infuse 0.9% saline IV or ____________ IV at 20 mL/hr to maintain IV site patency. Ondansetron (Zofran) 4 mg slow IV over 2 minutes one time day of surgery only as needed for nausea. Prochlorperazine (Compazine) 5 mg slow IV over 2 minutes every 6 hours as needed for nausea. May repeat in 20 minutes. May give orally. 24-hour Max. dose is 40 mg. Metoclopramide (Reglan) ______ mg slow IV over 2 minutes every 4 hours as needed for nausea. (Do not give for colorectal surgery.) May give orally. Diphenhydramine (Benadryl) ______ mg slow IV over 2 minutes as needed for itching. May give orally. Hydroxyzine (Vistaril/Atarax) 25 mg IM or orally every 4 hours as needed for itching. Nalbuphine (Nubain) ______ mg slow IV over 2 minutes every 6 hours as needed for itching (recommended range 2.5–5 mg dose). Bowel care of choice: Bisacodyl (Dulcolax) ______ mg orally every ____________ as needed Docusate sodium ______ mg orally every ____________ as needed Other: _______________________________________________________________________________________________

Adjunct medications (may continue for 24 hours following discontinuation of PCA)

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Procedures One procedure indicated for Mr. Jensen is daily wound care. Order daily catheter care if the patient has an in- dwelling urinary catheter. Catheter-associated urinary tract infections are a major concern for hospital patients, and many EMR systems have an automatic order to remove any indwelling urinary catheter the first post- operative day unless otherwise ordered. If the catheter

is not removed, you are required to document the reason why, such as need for accurate intake and output (I&O) monitoring or surgery involving the genitourinary tract.

Laboratory and Other Diagnostic Studies Often laboratory studies are indicated in the postoperative period to help monitor for potential complications. A CBC is often ordered to monitor the WBC count and

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the H&H. You may order various chemistry panels, such as a basic metabolic panel (BMP), to monitor electro- lytes. Your order should indicate when the studies are to be done and for how many days, such as CBC daily x 3 days with routine morning labs or H&H stat, then every 8 hours x 24 hours.

Special Instructions Some special instruction orders might be prudent for Mr. Jensen. Because he has a history of HTN and usually takes antihypertensive medication, you would want to know whether his blood pressure was elevated above an acceptable level. Likewise, development of a fever would be important, and you would want to be notified if that occurred. When a patient is admitted under the care of a surgeon, there is often a need to obtain consultation with the hospitalist so he or she can manage the patient’s medical conditions; therefore, an order must be written for that consultation or any others that might be needed. A complete set of postoperative orders for Mr. Jensen is shown in Figure 10-8.

Computerized Physician Order Entry Even before the publication of the Institute of Medi- cine’s report To Err Is Human: Building a Safer Health System (Kohn et al, 2000) identified an unexpectedly high error rate in medical care, health-care providers recognized that the rate of medication errors and ad- verse drug events (ADEs) in hospitalized patients was unacceptably high. Since the report, awareness of the potential for severe harm from medication errors and of the frequency of ADEs has increased dramatically. Studies conducted after publication of the report con- cluded that a great number of medication errors and ADEs were preventable. One step that can be taken to reduce errors is to avoid using certain dangerous abbreviations, acronyms, and symbols when writing orders; in fact, since 2004, The Joint Commission has required organizations to have a “Do Not Use” list. The Institute for Safe Medication Practices (ISMP) also

Figure 10-8 Postoperative orders for Mr. Jensen.

XX/XX/XX

0723

1. Admit to Dr. Sanders, surgical floor

2. Dx: adenocarcinoma of colon; S/P right hemicolectomy

3. Condition: stable

4. Bedrest

5. VS q1h x 4; if stable q2h x 4; if stable q4h

6. Allergic to PENICILLIN

7. NPO

8. Incentive spirometry 10 times per hour while awake

9. I&O

10. D5 1/2 NS 150 mL/hr

11. Morphine sulfate 1 mg/mL by PCA; demand dose 1 mg, lockout every 12 minutes; 4-hour dose limit: 20 mg

12. Zofran 4 mg IV q4 hours PRN nausea

13. Routine wound care

14. Routine catheter care

15. Notify if systolic pressure greater than 150 mm Hg or HR greater than 130

Signature, Credential: ___________________________________________________________

Countersignature: ______________________________________________________________

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provides a list of Error-Prone Abbreviations, Symbols and Dose Designations, which is shown in Appendix C. The increasing concerns for safety and the desire for reducing and preventing medication errors have resulted in adoption of Computerized Physician (or Provider) Order Entry (CPOE) in many hospital systems.

Osheroff and associates (2012) define CPOE as “the portion of a clinical information system that enables a patient’s care provider to enter an order for a medica- tion, clinical laboratory or radiology test, or procedure directly into a computer that then transmits the order to the appropriate department, or individuals, so it can be carried out.”

Benefits of CPOE Bobb and colleagues (2004) found that of 1,111 pre- scribing errors confirmed in their study, 65% were likely preventable with a basic CPOE system. Other studies report preventable errors in the range of 43% to 72%. The number of potential preventable errors that was identified increased when basic CPOE was used in conjunction with the Clinical Decision Support System (CDSS). CDSS consists of automated checking to: • Identify potential drug dose, allergy, and interac-

tion errors. • Notify of duplicate orders. • Recommend pre-administration or postadminis-

tration tests. • Provide access to clinical reference information,

research, and guidelines. • Substitute medication and test recommendations.

Some CDSSs can also monitor patient treatment, ensuring, for example, that the right drug is adminis- tered to the right patient at the right time and can issue an alert or reminder and suggest a different course of treatment if a patient’s condition changes or if test results are abnormal. Most CDSSs can provide health-care professionals with immediate electronic access to their orders and comprehensive views of patient clinical data and laboratory test results, allowing providers to make more informed decisions about medications. Studies of usage of CPOEs in major hospitals have found cost savings, increased use of preventive care interventions, and improved clinical care. The literature supports the beneficial effect of CPOE in reducing the frequency of a range of medication errors, including serious errors with the potential for harm. CPOE integrates the med- ication order with patient information, such as allergies, laboratory results, and other prescription data. Then the order is checked automatically for potential errors or problems, such as drug and allergy interactions or drug-to-drug interactions. CPOE systems also suggest default values for drug doses as well as routes and frequency of administration. After implementation of

CPOE, studies have reported a reduction up to 70% in medication errors (Devine et al, 2010) and a significant decrease in medication orders that were inappropriate (Mattison et al, 2010). The average time from medica- tion ordering to administration decreased from 100 to 64 minutes (Cartmill et al, 2012). The costs of avoiding ADEs ranged from $7 to $16 million (Zimlichman et al, 2013), and the incidence of duplicated orders decreased by 84.8%, resulting in additional cost savings for the institution (Magid et al, 2012). According to the results of the 2016 Leapfrog Hospital Survey, 1,394 (75%) hospitals reported using a CPOE system in at least one inpatient unit, compared with 384 in 2010.

Challenges and Barriers to CPOE One particular challenge associated with CPOE is selec- tion error. When a medication order is entered, usually the computer system will display a list of drug names after a few letters have been entered. For example, if you enter the letters m-e-t, medications such as Metamucil, metformin, methadone, metaxalone, methyldopa and metoprolol may show up on a selection list (Fig. 10-9a). Then you select the desired medication, but it is easy to inadvertently select the wrong drug name. Once a drug is selected, common doses will populate (Fig. 10-9b). You must be cautious to select the correct medication and dose. Another challenge associated with CPOE is “alert fatigue.” The CDSS is designed to alert the pro- vider when there are potential drug–drug interactions, drug contraindications, drug–disease interactions, and drug allergies. Alert fatigue is caused by a combina- tion of critical medical alerts and a high volume of marginally medically consequential alerts. Redundant alerts can reduce providers’ sensitivity to the alerts, resulting in the provider dismissing the alert without actually investigating the concern, thereby increasing the opportunity for patient safety error.

When EMRs were initially introduced, many systems did not include CPOE. Implementing a CPOE system is always a challenge, and several barriers to CPOE use have been identified. CPOE has a considerable impact on work flow for health-care providers and hospital staff. Issues with interoperability with the EMR and CPOE systems are barriers to implementation. The time required to train providers and staff is substantial. Often, any pre-existing order sets must be modified or completely restructured for the CPOE system, which is a labor- and resource-intensive process. Functional problems often arise, so the availability of technical support is critical in implementing and ongoing use of CPOE. Because of the nuances and complexities of the health-care environment, the standard information technology (IT) staff may not be able to resolve issues with CPOE function, and often they need input directly from health-care providers and other staff to understand

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Figure 10-9 One particular challenge associated with CPOE is selection error. (a) When a medication order is entered, usually the computer system will display a list of drug names after a few letters have been entered. It is easy to inadvertently select the wrong drug name. (b) Once a drug is selected, common doses will populate. You must be cautious to select the correct medication and dose.

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work-flow issues and the medical significance of various processes. Appropriate support must be available around the clock, 365 days a year, which often results in hiring more staff at expense to the institution. Because of the continuous introduction of new medications, changes in indications or contraindications for medications, and availability of new diagnostic tests, regular system updates must occur, resulting in ongoing training for system users and support staff. Every upgrade has the potential to disrupt work flow and impact functionality, which, in turn, may impact patient safety. Especially for small and rural hospitals, the cost of implementing CPOE is a considerable barrier; cost for a very basic CPOE system starts at around $1.5 million; in larger hospitals, the cost may be more than $10 million.

Admit Notes Records such as admission H&Ps, operative reports, and discharge summaries are sometimes dictated, resulting in a delay between the time of dictation and when the transcribed record appears on the chart or in the EMR. Because of this delay, it is customary to write a brief admit note. The purpose of the admit note is to summarize the admission H&P and to provide infor- mation that will be needed to care for the patient until the dictated records get to the chart. Document that an admission H&P has been performed and dictated, indicating the date and time it was done. This informs other medical staff members that the H&P has been done so that it will not be duplicated. It also serves as documentation that the H&P has been completed in the required time. Most dictation systems assign a job number or report identifier; this should be documented as well in case dictations are lost or there is interrupted

service. If a voice recognition system is used to generate the H&P, the document is saved into the EMR right away, and then an admit note is not needed.

The admit note is a permanent part of the medical record. As such, it should be thorough enough to com- municate the reason for the patient’s hospitalization and should include the presumptive diagnosis and treatment plan, but keep in mind that it is a brief summary of the H&P. An admit note typically contains the patient’s identifying information, reason for admission, pertinent past medical history, medications, allergies, pertinent findings from the physical examination, pertinent lab- oratory data, admitting diagnosis, and a summary of the treatment plan. It is usually written as a narrative paragraph. Example 10.5 shows an admit note.

EXAMPLE 10.5

Admit note: S.B. is a 72-year-old woman who devel- oped symptoms of fever and cough 2 days ago and has had progressive dyspnea. Her past medical histor y is significant for chronic obstructive pulmonary disease (COPD) and HTN. She takes Accupril 10 mg daily and uses a Combivent inhaler twice daily. On physical ex- amination, she is febrile and dyspneic but not cyanotic. Crackles are heard in the right posterior lung. Hear t is tachycardic but regular, with a rate of 112. Chest x-ray reveals an RLL infiltrate. Presumptive diagnosis is RLL pneumonia. S.B. is admitted to the medical ser vice for IV antibiotic therapy and suppor tive respiratory care. H&P done and dictated 8/22/XX, 1543; job ID 1564273. Rachel Alford, MD

Referring to the information found in the H&P for Mr. Jensen (see Fig. 10-2) and the admit note shown in Example 10.5, write an admit note in the space provided.

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238 | Guide to Clinical Documentation

Summary Hundreds of thousands of hospital admissions occur annually in the United States. Often patients are over- whelmed and feel vulnerable when faced with a hospital stay. You as a provider can have a positive impact on patients and their health, yet you also are vulnerable because you must navigate sometimes complex EMR systems to document patient care appropriately and continually evaluate and manage complex medical conditions. The admission process presents unique challenges for the health-care team and has tremendous

impact on the entire hospital stay. You must give meticulous care and attention to documenting the admission H&P and generating orders, especially when orders relate to medication administration. CPOE and CDSS are designed to assist health-care providers in successfully completing these tasks and have helped reduce the number of medication errors and ADEs, yet there are still barriers to CPOE use. To reinforce the content of this chapter, please complete the worksheets that follow. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

Application Exercise 10.1 Label this entry as an admit note, record the date and time, and provide the information as indicated in Example 10.5. Admit notes for surgical admissions do not vary greatly from those for medical admissions. The plan of treatment is the surgical procedure that the patient is scheduled to have.

Once you have completed the admit note, compare it with the one that follows.

Application Exercise 10.1 Answer Admit Note: Mr. Jensen is a 67-year-old man who has colon cancer. Mr. Jensen originally presented with complaints of fatigue and on workup was found to have blood in the stool. Colonoscopy revealed a mass and biopsy showed adenocarcinoma. Past medical history is significant for hypertension and hypercholesterolemia. He is taking Lotensin HCT 20/12.5 once daily in the morning and Mevacor 20 mg once daily in the afternoon. He is allergic to penicillin, which causes a rash. Laboratory studies done at time of admission reveal that the CBC is normal; the chemistry panel reveals triglyceride of 178; LDL of 208; total cholesterol of 267; CEA of 17; otherwise WNL. CXR shows borderline cardiomeg- aly but no effusion. The ECG is WNL. Mr. Jensen is admitted for elective right hemicolectomy. Routine pre-operative orders are written. H&P done and dictated xx/xx/xx 0927. David Sanders, MD

Dictation # 478432

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Worksheet 10.1

Name:

Admission H&P for C.H.

Read and critically analyze the admission H&P for C.H. shown in Figure 10-10. Answer the questions that follow.

1. Is this a medical or surgical admission?

2. The medication listed for this patient is aspirin. Based on the documented PMH, what is the indication for

this medication?

3. What additional information should be documented about the medication?

4. Do you feel that the information documented in the social history is sufficient? Why or why not?

5. List the systems explored in the ROS and the total number of systems reviewed.

6. Does the ROS meet CMS guidelines for documentation? Why or why not?

7. Do you think the H&P contains enough information to justify hospital admission? Why or why not?

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Admission H&P for C.H.

Patient: C.H. MRN: 14-28-75

Sex: male DOB: 8/1/19XX Billing #: M49223-7

Admitting Physician: Samuel Mason, MD Date of Admission: XX/XX/20XX

CHIEF COMPLAINT: Urinary frequency and urgency

HISTORY OF PRESENT ILLNESS: This is a pleasant 76-year-old man who has been having urinary urgency and frequency for the past week. Two days ago, he developed a fever. He remains febrile now and has experienced nausea but no vomiting. He denies abdominal pain, chest pain, shortness of breath, or diarrhea. He does have a history of benign prostatic hyperplasia.

PAST MEDICAL HISTORY: 1. Status post-TURP for benign prostatic hyperplasia. 2. Inguinal hernia status post repair. 3. Carpal tunnel with repair.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

MEDICATIONS: Aspirin only.

FAMILY HISTORY: Father and brother both had BPH.

SOCIAL HISTORY: The patient is a former smoker, quit many years ago. Denies drug use. He drinks alcohol socially.

REVIEW OF SYMPTOMS: The patient denies any palpitations, chest pain, weakness, headaches, vision changes, nausea, vomiting, abdominal pain. He did say that he had a history of blood clots due to an injury. This happened many years ago, he doesn’t recall the specific date or his age at the time but says it was when he was in his 40s. He has never had any problems since.

PHYSICAL EXAMINATION: Vital Signs: Blood pressure is 128/69, pulse is 84, temperature is 100.3ºF with O2 sats 93% on room air, weight is 184 lb.

General: He is alert, awake, pleasant and in no acute distress.

Head: Head is atraumatic, normocephalic. EOMs are intact. No scleral icterus.

Neck: No lymphadenopathy noted. Cardiovascular: Regular rate. Normal S1, S2 without any murmurs or JVD.

Abdomen: Soft, nontender, nondistended. No pain in the hypogastric area. No costovertebral angle tenderness. No rebound tenderness or guarding.

Extremities: Nonedematous. Peripheral pulses present. No clubbing or cyanosis.

Neurological: The patient is alert and oriented to time, place, and person. He responded to all questions appropriately. No focal neurological deficits.

LABORATORY DATA: CBC: WBC 12.9, hemoglobin 12.8, hematocrit 36.4 with neutrophils 83%. INR 1.2. Creatinine 1.4, BUN 25, sodium 134, potassium 3.9, chloride 99, bicarbonate 24. The CT scan of the abdomen revealed diverticulosis of the colon with thickening of the sigmoid colon suspicious of intramural diverticulitis. No abscess or free air. No hydronephrosis or stones.

ASSESSMENT: 1. Febrile. 2. Urine frequency, urgency. 3. Leukocytosis. 4. Hematuria. 5. Bacteriuria. 6. Acute renal failure. 7. CT scan of abdomen showed diverticulosis and thickening of the sigmoid colon; intramural diverticulitis. 8. History of TURP.

PLAN: 1. Obtain urine cultures, stain, sensitivity. 2. Blood cultures. 3. IV fluid resuscitation. 4. Start IV Flagyl. 5. Check PSA. Urology consultation and possible cystoscopy if urology recommends. 6. GI prophylaxis with Nexium. 7. Further plans depending on the hospital course.

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8. Read the assessment section and then the laboratory data section. Identify any additional information that

you think should be recorded in the laboratory data section.

9. After reading and critically analyzing the H&P, identify strengths and weaknesses of the document.

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Worksheet 10.2

Name:

Admit Orders for C.H.

Read the admission H&P for C.H. shown in Figure 10-10. Using the mnemonic AD CAVA DIMPLS shown in

Figure 10-4, write admission orders to reflect the assessment and plan.

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Worksheet 10.3

Name:

Admit Note for C.H.

Read the admission H&P for C.H. shown in Figure 10-10. Write an admit note based on the information

documented in the H&P and using the notes in Examples 10.3 and 10.4 as a reference.

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Worksheet 10.4

Name:

Admission H&P for G.M.

Read and critically analyze the admission H&P for G.M. shown in Figure 10-11. Answer the questions that follow.

1. Is this a medical or surgical admission?

2. Review the PMH and identify strengths and weaknesses as documented.

3. The author states, “10-point review of systems is negative.” Identify any information you find in other

parts of the document that could be counted as ROS. List the systems reviewed and the total number of

systems reviewed.

4. Based on the discussion of documenting the social history in Chapter 2, what elements could be added to

the social history to make it more complete?

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Patient: G.M. MRN: 68-25-71

Sex: female DOB: 1/29/19XX Billing #: M452941-2

Admitting Physician: JoAnn Brooks, MD Date of Admission: XX/XX/20XX

Primary Care Physician: Dr. Charles Rosenberg

CHIEF COMPLAINT: “Feeling lightheaded.”

HISTORY OF PRESENT ILLNESS: The patient is a very pleasant 74-year-old woman who came to see Dr. Rosenberg today for a routine office physical examination and was noted to have a rapid heart rate. ECG obtained in his office showed atrial fibrillation with a rate in the 150s. No prior history of palpitations. The patient states that she felt lightheaded most of the day yesterday, and intermittently today. She denies syncope, headache, or visual changes. No chest pain or pressure, no shortness of breath. No other dizziness, focal numbness or weakness, speech difficulties, trouble swallowing, or difficulty moving extremities. No abdominal pain, recent diarrhea, or constipation. She does not exercise regularly but does do her own housework without any chest pressure or exertional dyspnea.

PAST MEDICAL HISTORY: 1. Diabetes mellitus, type 2. 2. Peripheral neuropathy due to diabetes. 3. Osteoporosis with vertebral compression fracture requiring kyphoplasty. 4. Kyphosis. 5. Hypertension. 6. 1–2+ mitral regurgitation.

ALLERGIES: PENICILLIN AND SULFA MEDICATIONS.

MEDICATIONS: 1. Lantus 22 units in the morning subcutaneously 2. Lisinopril 5 mg daily 3. Omeprazole 40 mg daily 4. Celebrex 200 mg daily 5. Xanax 0.25 mg twice daily 6. Aspirin 81 mg PO daily 7. Boniva 150 mg monthly 8. Mirtazapine 30 mg nightly

FAMILY HISTORY: Family history is remarkable for both parents dying in their early 40s. Her mother had uncontrolled hypertension, died from a stroke. Her father died from complications of long-standing diabetes.

SOCIAL HISTORY: The patient has been widowed since 2003. She has three daughters, one of whom lives nearby. She is a former smoker but quit in 2000. No significant alcohol intake.

REVIEW OF SYSTEMS: 10-point review of systems is negative.

PHYSICAL EXAMINATION: Vital Signs: Blood pressure is 109/67, pulse 110 and irregular. Weight is 147 lb. Respiratory rate is 16. She is afebrile.

General: She is alert and fully oriented.

Skin: No pallor or jaundice noted.

HEENT: No evidence of head trauma. Oropharnyx is clear.

Neck: Supple. No increased jugular venous distention or carotid bruits are noted.

Heart: Heart rate is irregular, slightly tachycardic with an intermittent 2/6 systolic murmur.

Lungs: Clear to auscultation bilaterally. She has marked kyphosis.

Abdomen: Abdomen is soft, nontender, nondistended.

Extremities: There is no peripheral edema. Distal pulses are present and normal. She has normal strength in both upper and lower extremities.

Neurological: Cranial nerves II–XII are intact.

LABORATORY STUDIES: ECG does show atrial fibrillation with rate of 150 with a right bundle branch block. WBC 9, Hgb 13.2, platelets 264,000, sodium 131, potassium 4.6, chloride 93, bicarb 25. BUN 17, creatinine 1.2, normal creatinine 0.9. Glucose 481.

(Continued)

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5. The Assessment and Plan portions in this admission H&P is a slightly different format compared with

other H&Ps you have seen in this chapter. Do you feel the Assessment and Plan sections, as documented,

sufficiently reflect a reason for hospitalization for this patient? Does the H&P meet CMS guidelines for

documentation? Why or why not?

Figure 10-11 Admission H&P for G.M.

Urinalysis had 6 WBCs. Hepatic function panel is within normal limits. TSH is within normal limits. Troponin was normal. Chest x-ray shows no active infiltrates.

ASSESSMENT: This is a very pleasant 74-year-old woman who presents with new-onset atrial fibrillation with rapid ventricular rate. She otherwise is fairly asymptomatic. Of note, she did have a recent 2-D echo in June of this past year, and it was essentially normal. There was some mild diastolic cardiac dysfunctions and 1–2 mitral regurgitation.

PLAN: 1. Atrial fibrillation. Will continue IV Cardizem, start on oral beta blocker and monitor heart rhythms. Will ask cardiology to consult. Continue to rule out myocardial infarction. Will give once-daily Lovenox. 2. Hypertension. Hold the ACE inhibitor at this time. 3. Osteoporosis. On treatment. 4. Diabetes mellitus, uncontrolled at this time. Will continue Lantus and institute insulin protocol.

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Worksheet 10.5

Name:

Admit Orders for G.M.

Read the admission H&P for G.M. shown in Figure 10-11. Using the mnemonic AD CAVA DIMPLS shown in

Figure 10-4, write admission orders to reflect the assessment and plan.

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Worksheet 10.6

Name:

Admit Note for G.M.

Read the admission H&P for G.M. in Figure 10-11. Write an admit note based on the information documented

in the H&P and using the notes in Examples 10.3 and 10.4 as a reference.

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Worksheet 10.7

Name:

Abbreviations

These abbreviations were introduced in Chapter 10. Beside each, write the meaning as indicated by the con-

tent of this chapter.

ADEs

AD CAVA DIMPLS

BMP

CAD

CMS

CPOE

CVA

D5NS

EMR

H&H

HHS

I&O

ISMP

NPSG

OCR

PACU

PCP

PRN

RLL

S/P

WNL

AMI

BRP

CBC

CDSS

COPD

CXR

ECG

E/M

H&P

HPI

HTN

NPO

OOB

PCA

PMH

ROS

SVN

TID

WBC

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257

Documenting Inpatient Care LEARNING OUTCOMES

• Identify specific content that should be documented in daily progress notes. • Document daily progress notes using the SOAP note format. • Write orders that reflect continuous monitoring of a patient’s condition and changes

in the patient’s care. • Identify elements of a consult note. • Identify elements of an operative report. • Discuss the difference between an operative report and an operative note. • Identify elements of a procedure note.

Introduction Completing the admission history and physical examina- tion (H&P) and writing the admit note and admission orders is generally the most time-intensive part of the hospital stay for you as the admitting provider. While a patient is in the hospital, you or a designee must visit the patient daily. This is often referred to as “making rounds” or “rounding on a patient.” The purpose of the daily visit is to see how patients are responding to therapeutic interventions, communicate results of laboratory or other diagnostic studies, discuss the on- going treatment plan, and determine whether any new problems have arisen. Some of the content documented in a daily progress note will be determined by whether the hospitalization is for a medical or surgical condition (discussed later); however, there are commonalities that would apply to either.

Daily Progress Note There may be specific progress note templates in the facility’s electronic medical record (EMR). If not, or if the charting is paper based, you may use the SOAP note format introduced in Chapter 3 to record information that you gathered during the daily visit.

Subjective information includes the patient’s own comments or complaints as well as comments made by family members or other health-care providers. Objective information includes a general assessment, pertinent findings from the physical examination, and review of laboratory or diagnostic test results; it may include measurements, such as vital signs or intake and output (I&O). Assessment data are used to document the patient’s response to therapy and how the patient is progressing as well as to identify any new problems. When applicable, documentation also must include any complications, hospital- acquired infections, and unfavorable reactions to drugs, including anesthesia. The plan outlines any changes needed in the present plan of care or initiates therapy for any new problems.

Content of a Daily Progress Note Medical Admissions Subjective Remember that documentation of an admission H&P is required within 48 hours of hospitalization although some institutions may have different requirements for the time to complete. Some institutions require documentation to reflect how many days the patient has been hospitalized, noted as “hospital day (HD) # ___”; some EMRs will display this automatically. The daily

Chapter 11

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progress note does not need to contain information already documented in the H&P; instead, it focuses on any changes that have occurred in the condition of the patient from one day to the next. It is sometimes helpful to ask the patient a general question, such as, “Do you feel better, worse, or about the same?” The answer to this question provides the patient’s perspective on his or her response to treatment and allows for comparison of how you think the patient is progressing. Document the continued presence or resolution of any symptoms that the patient had at the time of admission. For example, if a patient was admitted for treatment of urosepsis and had fever and dysuria at the time of admission, document whether the patient still has these symptoms. To assess the patient’s response to treatment or a procedure, you should anticipate what changes would be expected. The patient with urosepsis who is treated with antibiotics should become afebrile with corresponding decrease in the white blood cell (WBC) count, and you would expect the patient to have less dysuria. The patient should be monitored for development of symptoms that might indicate an adverse reaction to treatment. In the case of antibiotic administration, development of rash and difficulty breathing might indicate an adverse reaction, so the presence or absence of these symptoms is a pertinent positive or negative. In addi- tion to information that is obtained directly from the patient, the subjective portion could include review of notes from nursing staff, ancillary services personnel, or consulting providers as well as comments from staff or family members. As discussed in Chapter 10, if an interpreter is used for any part of the visit, be sure to document the name of the interpreter, identification number, modality (i.e., on-site or video remote inter- preting), and the language. If the patient is not able to provide information because of clinical condition or advanced dementia, and so on, you should document this specifically as well as documenting how you ob- tained any subjective information, such as from family members, staff, or review of records. Objective You will perform at least some physical examination during each daily visit. It is always important to docu- ment the general assessment, providing a comparison to when you last saw the patient. It is easy to overlook the importance of performing or documenting the general assessment. When documenting the general assessment, consider what would be important to know about the patient’s presentation one year from now with just your documentation as a memory aid. If a patient is complaining of severe pain not relieved by pain medication but is sitting up in the bed, alert and smiling, watching television, and conversing

with visitors, you might wonder about his or her statement of having severe pain. On the other hand, if the patient is lying curled in a fetal position, has the lights off, and is grimacing or moaning, this is a different assessment altogether. You are not likely to recall the details of the patient’s presentation, so document your observations. Vital signs are monitored and recorded at different intervals during a 24-hour period, depending on the frequency ordered. Some- times, you may summarize a range of results (e.g., pulse 80 to 104 in past 24 hours) or, for temperature, the maximum result, in the note. In the EMR, vital signs usually autopopulate into the record. How much physical examination you do depends largely on the reason for admission and your medical discipline. A patient being treated for a cerebrovascular accident who has comorbid conditions would require more extensive examination and, therefore, documenta- tion, than a patient admitted for pneumonia who is otherwise healthy.

It is essential to document review of all test results in a timely manner because missing an abnormal result could have a negative impact on the patient’s condition. You may use “shorthand” for documenting results of a complete blood count (CBC), electrolytes, or basic metabolic panel (BMP) (Fig. 11-1) in the paper-based daily progress note. This provides a way to compare the newest results with previous ones. In the EMR format, usually the results are autopopulated each day; some systems have a way to indicate that the results were reviewed, but if not, you should document this specifically. Typically, you would be able to view results outside of the note, and you can select a date range to see if there are previous study results available for comparison. Other objective information available to you are the notes written by other providers and staff; when you review others’ notes, be sure to document this as well. Assessment The Assessment section should reflect your evalu- ation of all the data available and any conclusions that you could draw from them. The assessment should indicate whether the patient’s condition is better, worse, or about the same since the last visit. If a patient was febrile at the time of admission but is now afebrile, your entry might read, Patient now afebrile; improved. If any new problems have been identified, you need to document them. When the patient has certain comorbid conditions, such as hypertension or diabetes, typically you will include these conditions in the Assessment section even if not the reason for hospitalization, and you would document your assessment of the condition, such as well controlled or stable.

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Chapter 11 Documenting Inpatient Care | 259

Figure 11-1 Written shorthand for documenting laboratory test results.

CBC

Hemoglobin

WBC

Hematocrit

Segs/bands/lymphs/monos/basos/eos

MCV/MCH/MCHC

Platelet count

Example:

5800

56 S/4 B/30 L/4 M/1 B/3 E

82/29/34

259,000

Electrolytes

Sodium

Potassium

Chloride

Bicarbonate

Example:

138

4.2

Comprehensive Metabolic Panel

Sodium

Potassium

Chloride

Bicarbonate

BUN

Glucose

Creatinine

Example:

138

4.2

104

1.2

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Plan The Plan section of the daily visit note outlines changes that will be made in the treatment regimen already in effect, either stating or inferring the rationale for these changes. For instance, if a patient was admitted for infection and started on a broad-spectrum antibiotic, you might decide to change antibiotics based on cul- ture results that had not been available at the time of admission. If a new problem has been identified, such as shortness of breath concerning for a pulmonary embolism, you should document the plan to address this concern. This may include procedures or diagnostic

tests to be done and any therapeutic interventions. You may indicate a consultation with a specialist as part of the plan.

MEDICOLEGAL ALERT !

When documenting daily rounds at facilities where EMRs are used, there is a temptation to speed up the process by copying and pasting entire notes or portions of notes. The practice of duplicating information within the same patient record or moving it across multiple

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Surgical Admissions Figure 11-2 illustrates the documentation of a daily progress note for a surgical patient. The note was created in an EMR and demonstrates important subjective and objective information that should be assessed for all surgical patients. When documenting the daily visit of a surgical patient, it is customary for you to label the note as “postoperative day (POD) #___,” indicating what number postoperative day it is. This is helpful when trying to determine whether the patient is progressing as expected after surgery because there is a fairly well-established time frame for certain events, such as when bowel function returns, when drains are removed, and healing of a surgical incision.

When rounding on postoperative patients, you can ask certain questions to guide your evaluation of the

patient each day. Is the patient getting adequate pain relief? Has bowel function returned? Can the patient’s activity level be advanced? Can the patient’s diet be advanced? Can any sutures, staples, tubes, or drains be removed? You should also determine whether any postoperative complications have occurred. You can anticipate what complications are likely based on the type of surgery that was done and then document enough information in the Subjective and Objective portions of the note to convey that such complications have or have not occurred.

Postoperative complications that can develop after almost any type of surgery include fever, urinary re- tention, fluid imbalance, and wound infection. More serious complications include hemorrhage, respiratory depression, and pulmonary or fat embolism. Fever is the most common postoperative complication and usually has one of five etiologies: respiratory, wound infection, urinary tract infection, thromboembolic event, or drug side effect or adverse reaction. You can remember these etiologies by thinking of “wind, wound, water, walk, and wonder drug” (the five Ws, explained in Table 11-1). This should prompt you to ask the patient about any symptoms that could indicate development of these complications, such as fever, cough, shortness of breath or difficulty breathing, increased pain at the operative site, and swelling of the legs or calf pain. You would document the answers as pertinent positives or negatives in the Subjective portion of the note.

Examining the cardiovascular and respiratory systems is part of the objective evaluation of most postoperative patients. Additionally, you should inspect the surgical incision or operative site and describe its appearance in the note. Document the presence of any drains and the amount and characteristic of any drainage. If the patient had general anesthesia, it is important to de- termine return of peristalsis. Document whether there is any abdominal distention and if bowel sounds are absent or present; if present, document the character of bowel sounds. Tailor the rest of the examination to the type of surgery that was performed. Do not neglect to assess for and document any pertinent findings related to pre-existing or comorbid conditions the patient may have. A sample progress note for POD #1 for Mr. Jensen is shown in Figure 11-3.

Daily Orders Any time there is a change in the plan of care for a hos- pitalized patient, you must write a corresponding order to reflect that change. Remember that in Chapter 10 we said that an order stays in effect until another order is written to modify or discontinue it. Once you have assessed the patient and recorded the daily progress

records creates potential risks to the integrity of the medical record, which include:

• Copying and pasting inaccurate or outdated information

• Redundant information in the EMR, which makes it difficult to identify the current information

• Inability to identify the author or intent of the documentation

• Inability to identify when the documentation was first created

• Propagation of false information • Internally inconsistent progress notes • Unnecessarily lengthy progress notes

The practice of copy/paste has become so widespread that a special study was done by the ECRI Institute in 2015 to explore its impact. In the report, authors dis- cuss three specific incidents where copying and pasting led to patient harm, even death. In one of the cases, a middle-aged man who was found to have atrial fibrilla- tion and potential heart disease during an emergency department visit was discharged to follow up with his primary care physician (PCP) for a stress test. The PCP failed to diagnose cardiac disease and copied and pasted the Assessment and Plan sections over 12 office visits during the next 2 years. The patient died from a heart attack, and the physician was successfully sued ( Samaritan, 2010). Aside from potential patient harm, EMR notes are being scrutinized by CMS and other payers to determine if copy/paste portions of the note constitute fraud, which could result in not only denial of payment but also civil and criminal penalties. Most institutions have policies regarding use of the copy/paste function, and several professional organizations have de- veloped policy statements addressing this practice. The message is clear : copy and paste with caution.

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Figure 11-2 Progress note from an EMR for a surgical patient.

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Category System When Fever Is Likely to Occur Potential Problems What to Assess

Wind Respiratory Within first 48 hr after surgery

Hypoventilation, atelectasis, pneumonia

Respiratory rate and effort, breath sounds

Wound Integumentary Postoperative days 4 to 7

Wound infection, abscess Amount and character of drainage, erythema, induration, increased tenderness at operative site

Water Urinary Anytime Urinary tract infection (UTI), sepsis

Fever, chills, flank pain, urgency, dysuria; amount, color, and smell of urine

Walk Vascular Postoperative days 5 to 14

Deep vein thrombosis (DVT)

Calf tenderness, swelling, temperature of extremities

Wonder drug

Multisystem Drug adverse reaction or drug–drug interaction

All medications the patient has had since surgery

Table 11-1 The Five Ws of Postoperative Fever

Figure 11-3 First postoperative day progress note for Mr. Jensen.

Date XX/XX/XXXX POD #1 Time 0823

S: Mr. Jensen states that he rested fairly well last night. He has had adequate pain relief with PCA dosing and had only one bolus dose. The nurse indicates that Mr. Jensen has been using the incentive spirometer every 4 hours when awake. He denies any N/V, fever, or chills. He does not have any complaints at this time.

O: Vital signs: BP 136/86, P 92, R 16, temp is 98.8. Maximum temp since surgery has been 99.1. I&O is 1,870 mL and 1,710 mL. On exam, Mr. Jensen is awake, alert, and cooperative.

Heart: RRR

Resp: Breathing somewhat shallow, but breath sounds are without any wheezing or crackles.

ABD: Soft, nondistended. No bowel sounds audible. Minimal tenderness to palpation around operative incision. There is a small amount of serosanguineous drainage noted on dressing. The wound edges are dry and intact, and there is no erythema or warmth around the incision.

EXT: Lower extremities reveal no calf tenderness or swelling, no warmth to touch. Distal pulses are intact and equal bilaterally.

GU: Urinary catheter in place with 75 mL of clear yellow urine in drainage bag.

A: S/P hemicolectomy, POD #1. Progressing as expected without complications.

P: Remove catheter. May have BRP. Advance activity to OOB at least TID.

Signature, Credentials:

Countersignature:

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note, you should write orders that correspond to any changes addressed in the plan. You might want to refer back to Figure 10-8 to review the postoperative orders that are currently in effect for Mr. Jensen. Now, look at the Plan portion of the SOAP note shown in Figure 11-3. You will notice that you need to write an order to remove the urinary catheter and another to change Mr. Jensen’s activity level to allow for bathroom privileges and for him to be out of bed at least three times a day. As with any entry in the medical chart, you should indicate the date and time, write the necessary orders, and then add your signature and title.

Any time you make a change in the management of the patient, you should evaluate the response to that change during the next visit. For instance, based on the plan documented in the POD #1 note, you wrote an order to remove the urinary catheter. The next time you round on Mr. Jensen, you should assess his response to removal of the catheter. Was he able to void after it was removed? Did he experience any urinary retention? Then document the response in the progress note.

Figure 11-3 shows POD #1 note for Mr. Jensen. Use Application Exercise 11.1 as an opportunity to write orders based on the Plan portion of the note.

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Application Exercise 11.1 Write orders that reflect the changes needed for Mr. Jensen’s care.

Application Exercise 11.1 Answer 1. Discontinue indwelling catheter. 2. OOB at least TID with bathroom privileges.

Next you will see the Subjective and Objective portions of the POD #2 note for Mr. Jensen. Use this

information to write the Assessment and Plan portions, and then write any orders necessary.

Application Exercise 11.2 Date, Time. POD #2 S: Mr. Jensen states that he rested fairly well last night. He is having adequate pain relief. He was able to void

after the catheter was removed. He experiences minor discomfort at the incision site when he gets out of bed but otherwise is comfortable. He denies any chest pain, shortness of breath (SOB), or difficulty breathing. He denies nausea or vomiting and states that he feels hungry. He continues to use the incentive spirometer (IS) every hour when awake. He does not have any complaints at this time.

O: Maximum blood pressure (BP) in the past 24 hours recorded as 152/94 with systolic consistently above 130 and diastolic consistently above 90. Maximum temperature since surgery has been 99.7˚F. I&O is 1,855 mL and 1,635 mL. On physical examination, Mr. Jensen is awake and cooperative; he is sitting up in the chair and does not appear to be in any discomfort. Heart exam reveals a regular rate and rhythm; normal S1 and S2; no gallop, murmur, or ectopy. There is no jugular venous distention (JVD) and no peripheral edema. Respirations are nonlabored, and there are normal breath sounds on auscultation of the lungs. The abdomen is soft, nondistended. Faint hypoactive bowel sounds heard throughout the abdomen. There is minimal tenderness to palpation around operative incision. Dressing is dry. Wound edges are intact, and there is no erythema or warmth around the incision. No calf tenderness to palpation. No swelling of lower extremities. Distal pulses are intact and equal bilaterally.

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Application Exercise 11.2 Answer Here is one possible way to document the Assessment and Plan for the POD #2 daily progress note:

A: 1. S/P hemicolectomy, POD #2. Progressing as expected. 2. Return of bowel function. 3. Wound healing without signs of infection. 4. Hypertension, previously stable on medication.

P: 1. Increase diet to clear liquids. 2. Continue routine wound care. 3. Resume prehospital medications of Lotensin and Mevacor. 4. Activity as tolerated.

Orders to correspond to your plan would read as follows:

1. Increase diet to clear liquids. 2. Activity as tolerated. 3. Lotensin HCT 20/12.5 mg one tablet PO daily. 4. Mevacor 20 mg one tablet PO daily.

Sometimes the Assessment and Plan portions of the note will be combined. An example of this, based on Application Exercise 11.2, is shown in Example 11.1.

EXAMPLE 11.1

A/P: 1. S/P hemicolectomy, POD #2: progressing as

expected. Activity as tolerated. 2. Return of bowel function: advance to clear liquid diet. 3. Wound healing without signs of infection: continue

routine wound care. 4. Hyper tension, previously stable on medication:

restar t Lotensin HCT 20/12.5 mg PO daily and Mevacor 20 mg PO daily.

Consult Note As we discussed in Chapter 10, a hospitalist, usually an internal medicine specialist, is the provider who oversees the patient’s hospitalization. Depending on what problems arise during the hospital stay, con- sultation with specialists may be necessary. A patient may have been admitted for diabetic ketoacidosis and while in the hospital developed cellulitis of the leg, which would prompt consultation with an infectious disease specialist. The same patient may experience new onset of atrial fibrillation, necessitating consultation with a cardiologist. Each specialist will document his or her consultation, and the note will be tailored to that specialist’s discipline. The consult note should indicate the discipline or specialty and the reason for the consult. The history of present illness (HPI), past medical history (PMH), and review of systems (ROS) are usually limited to the most pertinent information for each specialty (Fig. 11-4). Refer to Figure 10-10, the Admission H&P for C.H., which was authored by the hospitalist, Dr. Mason. As part of the plan of care, Dr. Mason includes obtaining urology consul- tation. Figure 11-5 shows a urology consult note for C.H. Also refer to Figure 10-11, the Admission H&P for G.M., noting where Dr. Brooks has indicated the need for a cardiology consultation, which is shown in Figure 11-6. Read and compare the two consult notes, noting how the history, examination, assessment, and plan are focused for each specialty.

MEDICOLEGAL ALERT !

Problems might arise when an intervention that should be done is omitted. An example is a patient who needs to have regular treatments with a bronchodilator but the order is never written. The patient develops respiratory difficulty because an intervention was warranted but not done. There might also be problems if an intervention is done longer than necessary. An example of this is when a patient has a urinary catheter that could be removed but the order is not written. The catheter remains in place lon- ger than necessary and the patient develops a UTI. Always remember to assess on a daily basis what interventions are indicated and which ones may be discontinued.

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Figure 11-4 Sample consult note from an EMR.

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Figure 11-5 Urology consult note for C.H.

PATIENT: C.H. MRN: 14-28-75

DOB: 8/1/xx Billing #: M49223-7

Date of Service: 1/13/XX

REASON FOR CONSULT: urinary frequency, urgency, UTI

CC: urinary frequency, urgency, fever

HPI: C.H. is a 76-year-old man who was admitted with fever and nausea. He developed fever 2 days ago. He complained of urinary frequency and urgency, which he has had for several months, but symptoms were acutely worse in the past 2 days. He also has nocturia, up 3–4 times a night. He has some mild dysuria. He denies flank pain or abdominal pain. He denies gross hematuria. On admission, urinalysis demonstrated bacteria and hematuria. PMH: TURP done about 10 years ago by an out-of-state urologist. Denies personal history of any GU malignancies. Remote history of kidney stones about 25 years ago; stone passed spontaneously without intervention.

Fam Hx: father and brother with BPH; no hx of prostate cancer that he is aware of.

Social Hx: not a current smoker, although he smoked 1 PPD for 30 years. Quit 10 years ago.

ROS: all systems reviewed and are negative except as documented in the HPI.

EXAM:

Temp: 100.5

General: A&O x 3, NAD

HEENT: normocephalic, atraumatic. Normal hearing. Wears glasses.

Neck: no masses

Resp: no increased respiratory effort; symmetrical chest expansion.

CV: normal peripheral pulses, no edema

Abd: soft, nondistended. No organomegaly.

GU: no CVA tenderness. Circumcised phallus without lesions or deformity. No scrotal swelling or tenderness. Rectal exam: smooth prostate, 40 grams, slight asymmetry with R greater than L, no nodules, no tenderness.

Neuro: CN 2–12 grossly intact, no focal deficits.

ASSESSMENT/PLAN: 1. BPH with LUTS: S/P TURP 10 years ago; now with urgency, frequency, nocturia. He has not been on alpha blockers, so will start him on Flomax 0.4 mg daily at bedtime. He will need PSA as an outpatient. Will check PVR to be sure he is not retaining urine. 2. UTI: UA nitrite + and with greater than 50 leukocytes. Await cultures; antibiotics per IM. 3. Microscopic hematuria: discussed hematuria differential diagnosis and workup, including cystoscopy, which will need to be completed as an outpatient when he is infection free. 4. Nephrolithiasis: remote history of stones.

Start Flomax, check PVR. Outpatient workup for hematuria.

Plan discussed with pt, RN.

Thank you for the referral and for allowing us to participate in care. We will follow with you.

Juan Munoz, MD

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Figure 11-6 Cardiology consult note for G.M.

PATIENT: G.M. MRN: 68-25-71

DOB: 1/29/XX Billing #: M452941-2

Date of Service: 4/7/XX

REASON FOR CONSULT: new-onset atrial fibrillation

CC: “lightheaded”

HPI: G.M. is a 74-year-old admitted from her PCP’s office. She had intermittent near-syncopal episodes for the past 2 days. At the PCP office, EKG was done and reportedly showed A Fib with RVR, although I cannot locate that EKG to review. EKG done on arrival here does show atrial fib with ventricular rate at 142. She denies chest pain or SOB. No DOE. Denies swelling of lower extremities. Denies prior cardiology workup.

PMH: HTN, type 2 diabetes, osteoporosis. No prior cardiac surgery. Takes ASA daily for the past 2 years although she does not recall why she started ASA.

Family HX: mother died of stroke at young age. Father deceased “diabetic complications.”

Social HX : former smoker, 1 PPD for approx. 25 years.

ROS: “lightheaded” episodically for the past 2 days; denies true syncope. Denies CP, SOB, cough, DOE, PND. Remaining systems negative.

EXAM: 74-year-old appears stated age and appropriate historian.

HEENT: unremarkable.

NECK: no JVD.

RESP: unlabored, CTAB.

CV: irregularly irregular, tachycardic; no M/R/G. No edema, 2+ peripheral pulses.

GI: soft, nondistended.

MSK: moves all 4 extremities.

SKIN: no cyanosis.

NEURO: no focal deficits.

PSYCH: cooperative with appropriate mood and affect.

TELE: A fib with vent rate 140s.

LABS: K+ 4.2; Na 139; Trop less than 0.01 ng/mL. CBC WNL. INR 1.0

EKG: by my interpretation, atrial fibrillation with RVR at 142 BPM

ASSESSMENT/PLAN: New-onset A Fib/RVR: continue IV Cardizem. Will start on oral as well at 60 mg q 6 hrs po and titrate down IV dose. CHADSVASC score = 4. Start warfarin 2 mg daily and monitor INR, goal 2–3. Stop ASA.

We will continue to follow.

Katrina Denton, MD

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Full Operative Report and Operative Note A full operative report, which provides a detailed narrative of the surgical procedure, must be documented for every patient undergoing surgery. The surgeon dictates this report. A full operative report for Mr. Jensen is shown in Figure 11-7. Because there could be a significant time lapse between the time the operative report is dictated and the time it is transcribed and placed in the chart, often the provider will write a brief operative note. This is similar to writing an admit note to summarize the admission H&P and indicating that it has been done and dictated. The operative note (or “op note”) is written in the chart or completed in the EMR immediately after surgery, and it remains part of the medical record even after the full transcribed operative report is placed in the chart. The operative note includes the following information: • Date of procedure • Name of procedure

• Indication: reason for the procedure • Surgeon • Surgical assistants, if any • Anesthesia: local, general, regional; name of

person administering anesthesia • Pre-operative diagnosis: presumptive diagnosis

before surgery • Postoperative diagnosis: most likely diagnosis

based on surgical findings • Descriptions

• Specimens: what tissue was removed and what studies were done

• Estimated blood loss (EBL) • Drains: types of drains, if any, and where placed

• Complications, if any (such as a nicked artery, punctured bowel, or complications from anesthesia)

• Disposition

Review the full operative report for Mr. Jensen shown in Figure 11-7 and complete Application Exercise 11.3.

Figure 11-7 Full operative report.

DATE OF PROCEDURE: XX/XX/XXXX

PROCEDURE: Right hemicolectomy

INDICATION: Adenocarcinoma diagnosed by tissue biopsy

SURGEON: David K. Sanders, MD SURGICAL ASSISTANT: Debbie Sullivan, PA-C

ANESTHESIA: General, by Paul Bartlett, MD

PRE-OPERATIVE DIAGNOSIS: Adenocarcinoma, right colon

POSTOPERATIVE DIAGNOSIS: Adenocarcinoma, right colon

DESCRIPTION: Under endotracheal anesthesia, the patient’s abdomen was prepped and draped. A midline incision was made. The liver was normal, except for a small cyst of the lateral aspect of the left lateral segment. The stomach, spleen, small bowel, and retroperitoneum were normal. There were no stones in the gallbladder. The colon was remarkable for a mass in the right colon. The right colon was mobilized and the ureter identified and preserved. The gastrocolic ligament was divided along its right side. The ileocolic vessels were transected near their takeoff from the SMA and ligated with absorbable suture. The remaining mesentery was divided between clamps and ligated. The bowel ends were transected using a stapler. The resection included the right branch of the middle colic artery, and resection margins were in the distal ileum and transverse colon. Two tissue samples were obtained, one from the distal ileum and one from the transverse colon. An ileotransverse colostomy was performed using staples. The mesenteric defect was closed with staples. Hemostasis was checked, and the incision was irrigated. The fascia was closed with a single layer of running #1 PDS. The subcutaneous tissues were irrigated, and the skin was closed with Vicryl. Estimated blood loss was 80 mL.

COMPLICATIONS: None

DISPOSITION: The patient was transferred to the PACU in stable condition.

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Application Exercise 11.3 Document an operative note for Mr. Jensen in the space provided. Date of procedure: Name of procedure: Indication: Surgeon: Surgical assistant: Anesthesia: Pre-operative diagnosis: Postoperative diagnosis: Description: Complications: Disposition:

Application Exercise 11.3 Answer Here is one way the operative note for Mr. Jensen could be documented.

Date of procedure: xx/xx/xxxx Name of procedure: Right hemicolectomy Indication: Adenocarcinoma of the colon Surgeon: D. Sanders, MD Surgical assistant: D. Sullivan, PA-C Anesthesia: General Pre-operative diagnosis: Adenocarcinoma, right colon Postoperative diagnosis: Adenocarcinoma, right colon Description: No unexpected findings, no evidence of metastasis, two tissue samples obtained for pathology; EBL 80 mL Complications: None Disposition: To recovery in stable condition.

Other Types of Documents In addition to admission H&Ps, admit notes, daily progress notes, and operative notes, other types of documents are frequently created during the course of a patient’s hospital stay. Procedure notes are discussed in this chapter; discharge summaries and discharge orders are discussed in Chapter 12 as are documentation related to patient elopement and a patient leaving the hospital against medical advice. Procedure Note The purpose of the procedure note is to document why and how a procedure was done and the patient’s response to the procedure. The usual format includes the following elements: • Name of the procedure • Indication for the procedure

• Consent (if required, including risks and benefits, potential complications, and name and relationship of person giving consent)

• Anesthesia (if applicable) • Details of the procedure • Findings (if relevant) • Complications

Suppose that, while he was in the hospital, Mr. Jensen fell and sustained a laceration to the scalp. You are called to evaluate him and, after examination, you determine that the laceration requires closure. After the laceration is repaired, you document the procedure. You could use the SOAP note format; however, it is more likely that you would write a pro- cedure note instead. Example 11.2 shows a procedure note documenting the repair of Mr. Jensen’s scalp laceration.

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EXAMPLE 11.2

xx/xx/xxxx Procedure Note 1845 Procedure: Laceration repair Indication: 2-cm full-thickness scalp laceration of the

right occipital area Consent: Discussed with Mr. Jensen the need for lacera-

tion repair ; possible complications of infection, bleed- ing; verbal consent for repair given by Mr. Jensen

Anesthesia: Local with 1% lidocaine with epinephrine Procedure: The area was prepped and draped in the

usual sterile fashion. After administration of local anesthesia, the wound was explored; no foreign bodies or step-offs were palpated. The wound was cleansed with Hibiclens and sterile water. The lac- eration was repaired with 3.0 nylon suture with a total of four interrupted sutures. Good approxima- tion and hemostasis was achieved. Topical antibi- otic ointment was applied.

Complications: None Signature, title

You may use the procedure note in many settings for a variety of procedures. You could use the note to

MEDICOLEGAL ALERT !

The issues related to consent are complex. Consent is not merely a form that needs to be completed; obtaining the patient’s consent means obtaining the patient’s au- thorization for diagnosis and treatment. The person being asked to consent to a procedure must have the capacity to understand the rationale for the procedure, any alter- natives to the procedure, and risks and benefits of the procedure. It is the responsibility of the provider who will perform the procedure to provide enough information to the patient so that he or she can make an informed decision. Courts have consistently held that it is not the responsibility of the hospital or health-care organization or any of its employees to obtain consent. State laws may regulate who is responsible for obtaining consent and who may give consent if the patient is unable to consent.

document a biopsy done at a dermatology office, removal of a toenail at a primary care clinic, or thoracentesis done in the emergency department. Figures 11-8 and 11-9 show two different procedure notes.

Figure 11-9 Procedure note for skin biopsy.

Site: left lateral leg, 3 cm above lateral malleolus

After obtaining informed consent, the area was prepped and draped in the usual fashion.

Anesthesia was obtained with 1% lidocaine with epinephrine.

A full-thickness punch biopsy was obtained with a 4 mm punch. Wound closed with two simple interrupted sutures of 4-0 Ethilon.

Sutures out in 5 days. Wound care discussed.

Specimen sent for dermatopathology.

Petra Ruslan, FNP

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Figure 11-8 Procedure note for incision and drainage.

Patient had an abscess of the right axilla, approximately 3 x 2 cm.

The local area was first anesthetized using 2% lidocaine with epinephrine.

Then the area was prepped in a sterile fashion, and utilizing a #11 blade scalpel, I made a surgical incision over the most fluctuant area.

I then expressed any pus that I could from the area, followed by pulse irrigation with NS.

Then I used a 1/4 inch iodoform packing to pack the wound gently.

The patient tolerated the procedure well, and a dressing was placed. The patient was informed that the packing should be removed in about 2 or 3 days. He may follow up with his PCP to have this done, or may return to our ED for re-evaluation, and packing removal. See ED note for final disposition.

Allen Robinson, PA-C

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Summary The average length of hospital stay is 4.8 days. During a hospitalization, the attending physician must assess his or her patients on a daily basis, document the patients’ response to therapy, and determine what changes, if any, are needed for each patient’s plan of care. Orders written by treating providers direct the health-care team in all aspects of care, from obtaining vital signs to administering medication. In addition to the attending physician, various specialists and ancillary personnel may interact with patients. Each will have his or her own

focus of treatment and documentation. Well-written documentation from admission through discharge should provide a meaningful, unambiguous narrative of all treatment provided to the patient as well as his or her response to treatment. Providers must safeguard the integrity of the patient’s medical record and, therefore, should exercise extreme caution if copying and pasting any portion of the record. Completion of the worksheets that follow will help reinforce the content provided in this chapter. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

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Worksheet 11.1

Name: ��

Review

1. List several questions that should be answered daily for postoperative patients.

2. A postoperative patient has been on a full liquid diet for the past 24 hours. He now has full bowel sounds

and says he is hungry. Write an order for a change in diet.

3. List seven components of a procedure note.

4. List at least five components of an operative note.

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5. List at least three risks associated with copying and pasting notes.

6. List the five Ws that could be sources of postoperative fever.

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Worksheet 11.2

Name: ��

Operative Note for K.S.

K.S. is a 50-year-old woman who presents for elective right carpal tunnel release. After reading the operative

report shown in Figure 11-10, write an operative note.

Date of procedure: ��

Name of procedure: ��

Indication: ��

Surgeon: ��

Surgical assistant: ��

Anesthesia: ��

Pre-operative diagnosis: ��

Postoperative diagnosis: ��

Description: ��

Complications: ��

Disposition: ��

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Figure 11-10 Operative report for K.S.

PATIENT: K.S. Medical Record Number: 87-420-65 Same-Day Surgery Unit

DATE OF PROCEDURE: XX/XX/XXX

PROCEDURE: Right carpal tunnel release

INDICATION: Chronic right hand with intractable pain, numbness, and tingling

SURGEON: Ralph Benedict, DO

SURGICAL ASSISTANT: Susan Carmichael, PA-C

ANESTHESIA: Distal wrist block; Wendy Falconetti, CRNA

PRE-OPERATIVE DIAGNOSIS: Carpal tunnel syndrome, right hand

POSTOPERATIVE DIAGNOSIS: Carpal tunnel syndrome, right hand, severe

OPERATIVE INDICATIONS: A very active 50-year-old right-hand-dominant woman has had pain, numbness, and tingling in the right hand for more than 8 months. She had conservative medical management with splinting and exercises and did not improve. She has noticed increasing pain and night awakening over the past 2 months, interfering with her activities of daily living. Electromyography and nerve conduction studies confirmed median nerve compression. She failed nonoperative management. We discussed the risks, benefits, and possible complications of operative and continued nonoperative management, and she gave her fully informed consent to the following procedure.

OPERATIVE REPORT IN DETAIL: The patient was brought to the operating room and placed in the supine position on the operating room table. After adequate anesthesia, extremity was prepped and draped in usual sterile manner using a standard Betadine prep.

The right hand was elevated and exsanguinated using an Esmarch bandage, and the tourniquet was inflated to 250 mm Hg for about 25 minutes. Volar approach to the carpal ligament was performed incising the skin with a knife and using cautery for hemostasis. Tenotomy and forceps dissection carried out through the superficial palmar fascia, carried down to the volar carpal ligament, which was then transected sharply with a knife and carried proximal and distal under direct vision using the scissors and being careful to avoid the neurovascular structures.

Cautery was used for hemostasis. The nerve had an hourglass appearance where it was constricted as a result of the compression from the ligament, and so a small amount of Celestone was dripped onto the nerve to help quiet it down. The patient tolerated this portion of the procedure very well. The hand was then irrigated and closed with Monocryl and Prolene, and sterile compressive dressing was applied and the tourniquet deflated.

ESTIMATED BLOOD LOSS: Less than 40 mL

COMPLICATIONS: None

DISPOSITION: To recovery room awake, alert, and in stable condition

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Worksheet 11.3

Name: ��

Procedure Note for D.M.

D.M. is a 54-year-old man who was admitted for cirrhosis of the liver. An abdominal paracentesis was done

earlier today, and the following procedure note was written. After reading the note, answer the following

questions. Name of procedure: abdominal paracentesis Indication for procedure: ascites Consent: form signed by patient before procedure Anesthesia: local, total of 4 mL Procedure: area was prepped and draped in usual sterile fashion. A 20-gauge needle was inserted and ap- proximately 1,840 mL of fluid was removed. Fluid sent to lab for analysis.

Chris Reeder, MS-IV

1. What additional information about consent should be documented in the procedure note?

2. After critically analyzing the note and comparing it to the one presented in the chapter, what additional in-

formation should be documented in the note?

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Worksheet 11.4

Name: ��

Daily Visit SOAP Notes

Refer to Figure 10-10, Admission H&P for C.H. After reviewing the H&P, answer the questions that follow.

1. List at least three problems, symptoms, or complaints documented in the H&P that should be followed up

when rounding on C.H. the day after his admission and documented in the Subjective portion of the daily

visit note. State your rationale for including each one.

2. List at least three findings that should be documented in the Objective portion of the daily visit note, and

state your rationale for including each one.

Refer to Figure 10-11, admission H&P for G.M.

After reviewing the H&P, answer the following questions.

3. List at least three problems, symptoms, or complaints documented in the H&P that should be followed up

when rounding on G.M. the day after her admission and documented in the Subjective portion of the daily

visit note. State your rationale for including each one.

4. List at least three findings that should be documented in the Objective portion of the daily visit note, and

state your rationale for including each one.

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Worksheet 11.5

Name: ��

Abbreviations

These abbreviations were introduced in Chapter 11. Beside each, write the meaning as indicated by the

content of this chapter.

BMP BP

CBC EBL

EMR H&P

HD HPI

I&O IS

JVD PCP

PMH POD

ROS SOB

WBC

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285

Discharging Patients from the Hospital LEARNING OUTCOMES

• List specific components of discharge orders. • Discuss the importance of medication reconciliation at the time of discharge. • Discuss the content that should be included in a discharge summary. • Define leaving against medical advice and the documentation of this event. • Discuss patient elopement and documenting the event.

Introduction Events that occur during a hospitalization may have significant impact on a patient’s health. The patient may be dealing with new diagnoses and ongoing conditions, and he or she may feel anxious about going home. The process of transitioning from hospital-based care to community-based care presents several challenges. Hospital providers must consider many factors that contribute to patients’ readiness for discharge. Even though leaving the hospital, patients may sometimes require some form of ongoing care, and in such instances, the hospital staff must be sure that patients have the support they need with a specific goal of preventing hospital re-admission within 30 days. Hospitals with high re-admission rates are in danger of losing funding and reimbursement from Medicare. Studies (Allaudeen et al, 2011; Graham et al, 2015; Kruse et al, 2013) have identified several factors, both clinical and non- clinical, that increase a patient’s risk of re-admission. Clinical factors were high-risk medications, including anticoagulants, steroids, and narcotics; and comorbid- ities, including congestive heart failure, renal disease, diabetes, cancer, anemia, and weight loss. Nonclinical risk factors include lack of adequate support (social, familial, financial); premature discharge; nonadherence with follow-up procedures or instructions; substance abuse; homelessness; barriers to learning; and delay in seeking medical treatment at the first sign of recurring symptoms. Patients who have any of these risk factors

may benefit from more coordinated care management, intensive assessment, and additional services after hospital discharge.

The hospitalist and others involved in the patient’s care should provide clear instructions about specific care needed after discharge, symptoms that should be reported to providers, and when follow-up appointments are needed. In Chapter 10, we saw that specific orders are written when a patient is admitted to the hospital. Likewise, specific orders are written at the time of dis- charge. In addition to the discharge orders, a discharge summary must be completed and provided to members of the health-care team that will be involved in the patient’s care outside of the hospital environment. We again follow Mr. Jensen to see how discharge orders and discharge summaries are written.

Discharge Orders A summary of what is included in discharge orders is listed here, and a discussion of each element is pre- sented next. • Disposition (where the patient will go after

discharge from the hospital) • Activity with specific instructions • Diet • Medication reconciliation, including prehospital

medications that should be resumed or stopped as well as any new medications

Chapter 12

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• Follow-up instructions (who and when) • Notification instructions (signs or symptoms that

could signal complications)

Disposition The first part of the discharge order usually indicates the disposition, or where the patient will go when discharged. The patient may go home or may be trans- ferred to another facility, such as an extended care or rehabilitation facility. If the patient is discharged home but will need home health services, the arrangements for those services must be confirmed before the patient leaves the hospital so that there is no gap in care. In the case of Mr. Jensen, he will return home because he does not require specialized care.

Activity Level You should specify in the discharge orders the level of activity that the patient is allowed. Mr. Jensen has an abdominal incision so he should not do any heavy lifting or straining in order to prevent dehiscence of the wound. An order that says, avoid heavy lifting is vague, and the patient is usually not in the position to determine how much weight is too heavy. It is best to give a specific weight limit. A low weight is advised for Mr. Jensen; 10 pounds is the maximum he should lift, although some surgeons might limit the weight to 5 pounds. Often patients who have had surgery are instructed not to drive for a certain amount of time after surgery. For patients who have had abdominal surgery, the minimum restriction is usually 1 to 2 weeks; some procedures, especially orthopedic, might require a restriction period that is even longer. Patients should specifically be told not to drive or operate machinery if they are taking prescription pain medication; doing so is considered driving under the influence. If there are activity restrictions that affect a patient’s ability to return to the regular work duties, employers may require documentation of the specific limitations; that is, cannot stand for more than 2 hours at a time, no lifting greater than 10 pounds for 4 weeks, cannot sit for more than 2 hours at a time, and so on.

Mr. Jensen has a surgical incision so activity orders should include care of the wound or specific instructions related to the wound. The wound can get wet but should not be immersed in water. Therefore, an order should specify that he may shower but should not take a tub bath, sit in a hot tub, or go swimming. Mr. Jensen will need to continue wound care at home. Instead of writing out the specific wound care orders, you may write an order for the nursing staff to instruct on wound care.

Diet Consider what type of diet the patient should have at home. If a patient had surgery during the hospitalization

or could not eat or drink for other reasons, the diet is usually advanced to the prehospital diet over several days as the patient’s condition improves and the pa- tient meets certain criteria. Mr. Jensen has a history of hypertension and dyslipidemia so the diet instructions should reflect the need for a special diet. A reasonable plan for Mr. Jensen is a low-fat, low-cholesterol heart- healthy diet.

Medication Reconciliation Medication reconciliation, or medication review, is the process of verifying patient medication lists at a point of care transition, such as hospital admission and discharge, to identify which medications have been added, discontinued, or changed relative to pre- admission medication lists. (Medication recon- ciliation during the admission process is discussed in Chapter 10.) Performing medication reconciliation is a critical element of a successful discharge transition. It also provides an opportunity for you to ensure that patients understand what medications they are taking, how to take them, and why they are taking them. Once an accurate discharge medication list is generated (Fig. 12-1), you need to communicate this information clearly and effectively to the patient and/ or caregivers, and you should provide written instruc- tions to the patient with complete dosing instructions for each medication.

Just as you had to write orders for medications while the patient was hospitalized, your discharge orders should indicate what medications the patient will continue after discharge. First, consider what medi- cations the patient was taking before hospitalization. In Mr. Jensen’s case, he was taking Lotensin HCT 20/12.5 and Mevacor. Because these medications treat chronic conditions that he still has, they should be continued. You should write an order to continue usual dosages of these medications. Next, consider what medications might be indicated related to the reason for the hospitalization. Mr. Jensen had major abdominal surgery and will need pain medication after discharge. Usually, the same oral analgesic that was given in the hospital will be continued at home because its efficacy has been established and the patient has been tolerating it without any problems. You should write a prescription for any medications the patient has not taken previously so you will need to write a prescription for an analgesic (prescription writing is discussed in Chapter 9). Finally, consider whether other medications, prescription or over-the-counter, are needed. Some medications that may be needed include stool softeners, sleep aids, and nonsteroidal anti-inflammatory medications for mild to moderate pain. Be sure to write a prescription for any medications that are not available over the counter.

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Chapter 12 Discharging Patients from the Hospital | 287

Follow-Up Care and Notification Instructions Follow-up care should also be part of the discharge orders. Specify by whom and when the patient will be seen. Mr. Jensen will see the surgeon, Dr. Sanders, 2 weeks from the time of discharge for wound evaluation, removal of staples or sutures, and a routine postoperative checkup. Follow-up care should also include special in- structions for the patient, such as notifying Dr. Sanders if any symptoms of complications occur. You should specify which symptoms should be reported because the patient may not realize the importance of certain symptoms. Consider what postoperative complications might occur and what symptoms would be associated with those complications. Any patient who has had major abdominal surgery is at risk for developing wound infection, pneumonia, deep vein thrombosis, or pulmonary embolus. Symptoms that correspond to these conditions include fever, redness or increased pain at the incision site, difficulty breathing, and pain in the leg. “Fever” is somewhat subjective (just like “heavy lifting” discussed earlier), so it is best to state a specific temperature that would be of concern. A typical order would read, notify Dr. Sanders of temperature greater than

100.5˚F, redness or increased pain at incision site, cough, difficulty breathing, or pain or swelling of the leg.

Also Mr. Jensen would follow up with his primary care provider (PCP), Dr. Vernon Scott, because he has chronic conditions that need continued monitoring and management that typically the surgeon would not provide. The time frame of follow-up will vary depending on the patient’s overall health status and whether the chronic conditions are stable or unstable. Because Mr. Jensen’s hypertension and dyslipidemia are stable, he should see Dr. Scott in 1 to 2 weeks. Example 12.1 shows the complete set of discharge orders for Mr. Jensen.

EXAMPLE 12.1

1. Discharge to home. 2. No lifting greater than 10 pounds; no driving,

exercising, or strenuous activity until released by Dr. Sanders.

3. May shower but no tub bath, hot tub use, or swimming until released by Dr. Sanders.

4. Instruct on routine wound care. 5. Low-fat, low-cholesterol hear t-healthy diet. 6. Continue Lotensin HCT 20/12.5 and Mevacor

at home.

Figure 12-1 Performing medication reconciliation is a critical element of a successful discharge transition. Once you have generated an accurate discharge medication list, you should provide written instructions to the patient and caregivers with complete dosing instructions for each medication. Photo courtesy of Epic.

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7. Ibuprofen 800 mg PO q6h with food PRN mild to moderate pain.

8. Oxycodone 10 mg 1 or 2 tablets PO q4h PRN moderate to severe pain.

9. Colace 100 mg PO twice daily for 1 week to prevent constipation.

10. Follow-up with Dr. Sanders in 2 weeks. 11. Notify Dr. Sanders if temperature greater than

100.5˚F, redness or increased pain at incision site, cough, difficulty breathing, or pain or swelling in the legs.

12. Follow-up with Dr. Scott in 1 month for routine care.

for participating in federal reimbursement programs, for example, require that hospital records be completed within 30 days following the patient’s discharge. Hospitals may have their own requirement for when discharge summaries must be done, and the person responsible for completing the discharge summary may be placed on suspension if it is not done within the required time frame. Usually the discharge summary is dictated, and transcribed copies are placed in the chart and sent to the admitting physician and other consulting provid- ers as indicated. In some facilities, voice-recognition software programs may be used instead of dictation that requires transcription.

One sample format is provided here, and we will again refer to Mr. Jensen as we discuss the discharge summary. The format used for discharge summaries will vary from institution to institution. The headings shown below (and in Table 12-1) indicate what information should be part of the discharge summary.

• Date of admission • Date of discharge • Admitting diagnosis (or diagnoses) • Discharge diagnosis (or diagnoses) • Attending physician • Primary provider and consulting physician(s)

(if any) • Procedures (if any) • Brief history, pertinent physical examination find-

ings, and pertinent laboratory values (at time of admission)

• Hospital course • Condition at discharge • Disposition • Discharge medications • Discharge instructions and follow-up instructions

Dates of Admission and Discharge The dates of admission and discharge are easily deter- mined from the medical record.

Admitting and Discharge Diagnosis (or Diagnoses) The admitting diagnosis can be found in the initial admitting orders. The discharge diagnosis might be the same as or different from the admitting diagnosis or might include several diagnoses. If you have not been following the patient on a regular basis, you may have to read through the entire chart to identify all the diagnoses. The discharge diagnosis should be the primary reason for hospitalization; secondary diagnoses will be listed as well. For Mr. Jensen, adenocarcinoma of the colon is the discharge diagnosis with secondary diagnoses of hypertension and dyslipidemia.

MEDICOLEGAL ALERT !

Failure to provide adequate follow-up instructions is one of the leading causes of litigation against health-care providers in both inpatient and outpatient settings. It is your responsibility to anticipate what complications the patient might develop and to educate the patient on the signs and symptoms that could indicate such a complica- tion. Patients cannot be expected to know what signs or symptoms need to be reported. Follow-up instructions and the documentation of such instructions should be as specific as possible. It is a good idea to verify that the patient has understood the follow-up instructions by asking the patient to repeat back to you what he or she has heard about the follow-up instructions. Then docu- ment that the patient appeared to understand follow-up instructions. It is also recommended that you provide follow-up instructions in writing as well because the patient is not likely to remember everything that was said verbally. Include family members or others who may be caring for the patient after discharge and document who, besides the patient, received follow-up instructions. If the patient is non-English speaking or has low level En- glish proficiency, you should provide the written instruc- tions in the patient’s preferred language.

Discharge Summary The discharge summary is a synopsis of the patient’s entire hospitalization and is required for any hospital stay longer than 24 hours. Often, members of the health-care team, insurance carriers or other third-party payers, and quality assurance personnel request a copy of the discharge summary. The discharge summary must be completed before the hospital can submit for payment. For these reasons, you need to complete the discharge summary in a timely manner. Regulations

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Chapter 12 Discharging Patients from the Hospital | 289

Attending Physician, Primary Provider, and Consulting Physician The attending (or admitting) physician is the provider primarily responsible for the patient during the entire hospitalization. For a surgical admission, this is almost always the surgeon. For a medical admission, this is typically the hospitalist. When hospitalists manage the patient, a copy of the discharge summary should always be sent to the PCP to be kept with the patient’s records. This helps provide continuity of care and documents important details of the hospitalization that could affect management of the patient after hospitalization. Any consulting physicians involved in the care of the patient should be listed and should receive a copy of the discharge summary. It is recommended to include the name of consulting physicians and their specialty. This is particularly helpful when a patient has had a complicated hospital course and was seen by multiple specialists. This helps provide continuity of care and ensures that the PCP has a record of the specialists who have already seen the patient in case consultation is needed in the future.

Procedures You should list any surgical procedures the patient had during the hospitalization. Some diagnostic or therapeutic procedures should be listed as well, such

as a coronary arteriogram, a bronchoscopy, or wound debridement. Minor procedures, such as insertion or removal of a drain, are rarely included here.

Brief History, Pertinent Physical Examination Findings, and Pertinent Laboratory Values The brief history, pertinent physical examination findings, and laboratory data are in the admission history and physical examination (H&P). Do not repeat everything already documented in these sections; instead, highlight any pertinent findings that relate to the reason for the current hospitalization. The goal is to summarize the information already in the medical record. For the history, include enough information to indicate why hospitalization was necessary. In the case of Mr. Jensen, it is appropriate to mention his initial presentation of fatigue, the finding of blood in the stool, and the subse- quent diagnosis of adenocarcinoma. Pertinent findings from the past medical history, current medications, and allergies are customarily included in this section of the discharge summary. There were no significant findings from Mr. Jensen’s physical examination; thus, it is permissible to state The physical exam findings were unremarkable. You should summarize pertinent baseline laboratory data. For a surgical admission, the pre-operative hemoglobin and hematocrit (H&H) is

Item Description Date of admission List date of admission Date of discharge List date of discharge Admitting diagnosis (or diagnoses) Principal or presumptive reason(s) for admission Discharge diagnosis (or diagnoses) Actual or final reason(s) for admission that was(/were) evident by the time

of discharge Attending physician List attending physician Referring and consulting physician

(if any) List names of those who provided consultations for this patient during the course

of hospitalization; if none, omit heading Procedures (if any) If none, omit heading Brief history, pertinent

examination findings and pertinent laboratory values

Events leading up to hospitalization, pertinent PMH, pertinent examination findings at time of admission, and pertinent laboratory values at time of admission

Hospital course Narrative of the details of the daily progress of the patient and response to treatment Condition at discharge Avoid one-word descriptions, state why the patient is able to be discharged Disposition Where the patient will go at time of discharge (home, extended care facility, etc.) Discharge medication List prehospital medications as well as any medications added during hospitalization

that the patient will continue taking after discharge Discharge instructions and

follow-up Include activity level, signs or symptoms of potential complications that the patient

should report, and when the patient should be seen for follow-up Problem list Include discharge diagnosis, any pre-existing conditions or chronic problems as well

as any new problems the patient developed while in the hospital; indicate if active problem or resolved

Table 12-1 Discharge Summary Contents and Brief Description

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usually included (even if normal) as well as any ab- normal findings from chemistry studies, such as the carcinoembryonic antigen (CEA) of 17 for Mr. Jensen. His dyslipidemia is a chronic problem so you could document the total cholesterol and triglyceride values; however, because this chronic condition is not likely to have an effect on this hospitalization, it is not necessary to include these values. You would also document in the discharge summary any abnormality that needed correction before surgery or that would significantly affect the patient’s overall hospitalization.

Hospital Course The hospital course is the most important part of the discharge summary. It also can be the most difficult part to document. Up to this point, you have taken the information in the discharge summary directly from other sections of the medical record. The hospital course narrative is a summary of information that is already recorded in daily progress notes, consultants’ notes, or procedure notes, but the challenge is learning what to include and what can be omitted from the discharge

summary. It takes practice in the art and science of medicine and documentation to develop a concise and informative hospital course narrative without being too verbose or leaving out important details. Think of this section as the story of the course of events of the patient’s hospitalization. Summarize the daily progress of the patient and the patient’s response to treatment as documented in the daily progress notes. A great deal of detail usually is not needed but include enough information to avoid ambiguity or an incomplete record of the patient’s hospital stay. Some providers summa- rize the events of each hospital day; this format works well when the stay is brief and the patient’s recovery is uneventful. This approach is not recommended if the hospitalization is longer than 5 days or if the patient has multiple problems. In those instances, you might construct the narrative to summarize the details of each problem and the patient’s response to treatment for each problem. Some hospitals may require the use of a specific format. To gain experience summarizing details of a patient’s hospital stay, complete Application Exercise 12.1.

Application Exercise 12.1

Read the hospital course narrative for Mr. Jensen that is provided here. Mr. Jensen underwent an elective hemicolectomy without complications. Routine postoperative care was initiated. On POD 1, his maximum temperature was 99.1˚F; maximum heart rate was 98, and blood pressure range was 102/70 to 136/86. He had adequate pain relief with PCA morphine administration and required only one bolus dose. Mr. Jensen did not have any specific complaints. On exam, no bowel sounds were heard, so he was kept NPO with IV fluids. The wound edges were dry and intact without any warmth to touch or redness. On POD 2, Mr. Jensen’s diet was advanced to clear liquids, which he tolerated well. The catheter was removed, and he was able to void without difficulty. He was able to ambulate with assistance and did not have significant pain. Mr. Jensen had elevated blood pressure readings with systolic consistently above 130 and diastolic consistently above 90, so his antihypertensive medication was restarted. He was also started back on Mevacor. His physical exam was unchanged. On POD 3, the diet was advanced to full liquids. The PCA morphine was discontinued, and he was started on oral oxycodone. On POD 4, Mr. Jensen’s vital signs were all stable, the wound was healing as expected, and he was tolerating a regular diet. He was able to ambulate without assistance and felt to be ready for discharge. Based on the example, answer the following questions: • When did bowel sounds return? • Did Mr. Jensen have effective pain relief from the oral analgesic? • Did Mr. Jensen experience any postoperative complications?

Application Exercise 12.1 Answer • We could assume that bowel sounds returned on POD 2 because the diet was advanced from NPO to clear liquids, but this information is

not specifically mentioned. • There is no documentation of how Mr. Jensen tolerated the oral analgesic, nor is there any specific information about postoperative

complications. You might guess that, because none is mentioned, none occurred, but it is always best to provide enough information so that others reading the discharge summary do not have to guess or make assumptions.

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Condition at Discharge Your discharge summary should also include a specific assessment of the patient’s condition that should in- dicate why the patient is ready for discharge. Avoid one-word descriptions such as stable or improved. In the case of Mr. Jensen, you could state, Mr. Jensen is tolerating a regular diet, has adequate pain relief from oral analgesics, and he is able to ambulate without assistance and to perform activities of daily living. His postoperative recovery is progressing as expected without complications.

Disposition, Discharge Medications, Discharge Instructions, and Follow-Up Instructions The disposition indicates where the patient goes when leaving the hospital. If the patient is being transferred to another facility, you should document the reason for transfer. The discharge medications, instructions, and follow-up were discussed in the previous section on writing discharge orders. List the medications and document any specific instructions in this part of the discharge summary.

A discharge summary for Mr. Jensen is shown in Figure 12-2. After reading it, try to answer these ques- tions: When did bowel sounds return? Did Mr. Jensen have effective pain relief from the oral analgesic? Did he experience any postoperative complications? What medications will Mr. Jensen take at home? When will Mr. Jensen see Dr. Sanders? A well-written discharge summary will answer most questions a reader might have about the events of the hospitalization.

Patient Leaving Before Discharge Two events requiring careful documentation are patients leaving the hospital against medical advice (AMA) and elopement.

AMA If a patient is advised to remain in the hospital and he or she still chooses to leave, the patient is said to be leaving AMA. Patients leave AMA for a variety of reasons. When asked, they most commonly cite family problems or emergencies; personal or financial obliga- tions; feeling bored, fed up, or well enough to leave; or dissatisfaction with their treatment. Because most hospitals are smoke-free facilities, patients often leave simply because they want to smoke. If this is the case, the patient may be offered nicotine-replacement ther- apy and, if needed, anti-anxiety medication. Although many patients who leave AMA have substance abuse problems, few of them attribute their decision to leave to

their addiction. It seems likely that leaving AMA puts patients at increased risk for adverse health outcomes. This concern is supported by several studies that found that patients who leave AMA have significantly higher re-admission rates than other patients. Glasgow and colleagues (2010) conducted a study of general medical patients who left AMA. The study sample included 1,930,947 medical admissions to 129 hospitals from 2004 to 2008; 32,819 patients (1.70%) were discharged AMA. These patients had a higher 30-day re-admission rate and higher 30-day mortality rate.

When a patient states a desire to leave the hospital before being ready for discharge, it is your responsibility as the admitting (or attending) physician to determine if the patient has capacity to make informed decisions. The law dictates that a patient who has capacity has the right to refuse medical care, and treatment without consent may be considered battery. When a patient signs out AMA, he or she is exercising this right to refuse care. However, if a patient is not capable of making an informed decision, then you cannot ethically or legally allow a discharge that may imperil the patient’s life or health. A patient’s right to refuse care can be exercised only if a patient has decision-making capacity. An assessment of decision-making capacity focuses on a patient’s ability to understand and communicate a rational decision. This determination centers around whether a patient can manipulate information regard- ing a specific task or procedure. It does not require that a patient be free of mental illness or delusions. To have capacity the patient must have the ability to express a choice and communicate that choice, the ability to understand relevant information, the ability to appreciate the significance of the information and its consequences, and the ability to manipulate infor- mation. Capacity is not the same thing as competence. Competence is a legal determination made by a court; capacity can be evaluated by the hospitalist or attending physician. If you are not sure if a patient has capacity, then you may consult a psychiatrist to evaluate the patient and determine capacity. If the patient’s capacity is confirmed, then the patient may leave. Even if the patient is leaving AMA, you should make every effort to provide adequate discharge instructions and arrange for follow-up care. Remember to document the patient’s decision to leave AMA in the medical record. Typically, the patient is asked to sign a form indicating that he or she has decided to leave AMA. An example of such a form is shown in Figure 12-3. If the patient is deemed to lack capacity, then you should keep him or her in the hospital for further treatment, even if involuntary admission is necessary.

Your documentation should include the name and relationship to the patient (if applicable) of any witnesses to the conversation about the patient’s possible discharge.

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Discharge Summary for Mr. Jensen

PATIENT: William R. Jensen MR#: 35-87-26

ADMITTING PHYSICIAN: David K. Sanders, MD

Date of Admission: XX/XX/XXXX Date of Discharge: XX/XX/XXXX

Admitting Diagnosis: 1. Adenocarcinoma of right colon 2. HTN 3. Dyslipidemia

Discharge Diagnoses: 1. Right hemicolectomy 2. Adenocarcinoma of the colon 3. HTN well controlled 4. Dyslipidemia, fairly well controlled

PRIMARY CARE PHYSICIAN: Vernon Scott, MD

BRIEF HISTORY OF PRESENT ILLNESS: Mr. Jensen is a 67-year-old Caucasian male who was referred to me after being diagnosed with colon cancer. The patient underwent a diagnostic colonoscopy with biopsies, and pathology report indicated adenocarcinoma. After discussing with Mr. Jensen and his wife the types of treatment available, they both agreed to an elective right hemicolectomy.

PMH: Medical hx includes HTN and dyslipidemia. Surgical history includes repair of right rotator cuff 24 years ago and left inguinal herniorrhaphy 15 years ago. Current medications include Lotensin HCT 20/12.5 once daily and Mevacor 20 mg daily. He also takes a multivitamin daily and fish oil supplements twice daily. Patient is allergic to PENICILLIN, which causes a rash.

PHYSICAL EXAMINATION: GENERAL: BP 142/80, P 86 and regular, Temp 97.8 orally. Current weight 174 pounds. WDWN male, A & O x 3.

HEENT: Unremarkable.

NECK: Supple, full ROM.

RESP: Breath sounds without wheezing or crackles. Respiratory excursion symmetrical.

CV: Heart RRR without murmurs, gallops, or rubs. No JVD or peripheral edema. Distal pulses intact.

ABD: Soft, nontender. No masses or organomegaly. Bowel sounds physiological in all four quadrants. No guarding or rebound noted.

RECTAL/GU: Prostate nontender, not enlarged. Stool guaiac positive. External genitalia exam reveals a circumcised male, both testes descended. No testicular or scrotal masses.

LABORATORY: CBC: WBC 5,800; Hct 48; Hgb 16. Peripheral smear shows normochromic, normocytic cells, differential WNL. Chemistry panel shows triglycerides of 178; LDL of 208; total cholesterol of 267; CEA of 17; otherwise WNL. Chest x-ray: borderline cardiomegaly, no consolidations of effusions.

UA: Negative. PT, PTT: 12.4 and 31. ECG: Normal sinus rhythm with rate of 84. No ectopy, no ischemic changes.

HOSPITAL COURSE: Elective right hemicolectomy was performed XX/XX/XXXX without complications. Intra-operative findings were consistent with adenocarcinoma with no evidence of metastatic disease. IV of D5

1/2 NS and PCA with morphine for postoperative pain management. On POD #1, patient did not voice any complaints. Blood pressure was 138/88, heart rate 92 max, respirations 20 and shallow. Max temp of 99.1. On exam, good breath sounds in all lung fields, no wheezing or crackles. Heart RRR. Abd soft and nondistended. Incision dry and intact without erythema or drainage. No calf tenderness or swelling. Orders to discontinue catheter. On POD #2, patient remained afebrile, max temp of 98.8, all other vital signs stable, breath sounds clear, heart RRR. Faint bowel sounds were heard throughout. Wound healing well without signs of infection. IV analgesics discontinued, changed to oral Percocet. Restart prehospital meds. Diet advanced to clear liquids. On POD #3, patient reported good pain relief with PO meds and tolerating prehospital meds without difficulty. No nausea or vomiting with liquid diet. Full liquid diet was tolerated well. Patient reports having bowel movement (BM) this morning. Remained afebrile and all vital signs stable. No complaints. Lung and heart exam unchanged. No abdominal tenderness. Wound edges dry without erythema. Patient returned to regular diet. By POD #4, patient still afebrile, VS were WNL, wound healing without complications or signs of infection, tolerating regular diet and meds without difficulty. Patient ready for discharge.

(Continued)

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Chapter 12 Discharging Patients from the Hospital | 293

Figure 12-2 Discharge summary for Mr. Jensen.

DISCHARGE INSTRUCTIONS: Patient will follow up with Dr. Sanders in 1 week for suture removal and will follow up with Dr. Scott in 3 weeks for routine care. Continue wound care as instructed. He may shower and get the wound wet but should not take tub baths or swim. He should be on a low-fat, low-cholesterol diet. Activity level limited to no lifting over 10 pounds, no pulling or straining, until appointment with Dr. Sanders. Patient to notify Dr. Sanders if he develops temp greater than 100.5ºF, SOB, swelling in legs, leg pain, or severe abdominal pain, cramping, or rectal bleeding.

MEDICATIONS: Patient will continue Mevacor and Lotensin HCT. Given prescription for Percocet 5 mg, 1–2 po every 4–6 hr PRN pain. Mr. Jensen was advised not to drive, drink alcohol, or operate any machinery while taking the Percocet. He should also drink lots of water to help avoid constipation and may take Colace 100 mg (OTC) if needed.

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Figure 12-3 Sample AMA form.

Release Against Medical Advice Memorial Hospital

Patient Name: _____________________________________________________________________________________________

Medical Record Number: _____________________________________________________________________________________

Date: ___________________________________ Time: ________________________________________ AM PM

I understand that I am leaving the above facility against medical advice. I have been informed of the risks associated with leaving the facility and, knowing these risks, I wish to leave this facility. I assume full responsibility for my own care and welfare.

By signing this form, I release the attending physician, the facility, and its personnel from all liability for any adverse effects, which may result from my leaving against medical advice.

Patient Signature: __________________________________________________________________________________________

If the patient is unable to consent by reason of age or some other factor, state the reasons: _________________________________

_________________________________________________________________________________________________________

Signature of legally authorized representative: _____________________________________________________________________

Witness: __________________________________________________________________________________________________

Relation to Patient: __________________________________________________________________________________________

Attending Physician Signature: _________________________________________________________________________________

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Use direct quotes of the patient’s statements to explain why the patient wants to leave. Do not document your own interpretation of why the patient is leaving or include any judgmental or derogatory remarks about the patient. Make every effort to arrange follow-up care for the patient. Document the discharge instructions and follow-up care just as you would for any other patient. Example 12.2 shows one way to document a patient’s decision to leave AMA.

EXAMPLE 12.2

xx/xx/xxxx, 1548. I was informed by Karen Macayo, RN, nurse manager of telemetry 5B unit, that Mr. Sanford has decided to leave the hospital against medical advice. He states, “I am a single father and I just cannot stay here and leave my kids alone. My sister was taking care of them, but she has to leave.” We discussed the benefits

of him remaining in the hospital, primarily, continued investigation into the etiology of the chest pain he is experiencing and pain relief. The patient has capacity and understands the risks of leaving, including serious cardiac disease, permanent disability, and sudden cardiac death. Mr. Sanford had an oppor tunity to ask questions about his condition, and I answered them to the best of my ability. He has been informed that he may return for care at any time. A follow-up appointment with his PCP has been scheduled for 2 days from now.

Signature of attending physician

Elopement Elopement occurs when a patient leaves the hospital without being discharged and without the patient

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informing staff of the desire to leave. Eloping patients are often at risk for serious harm, and there are many cases in which patient elopement has resulted in death. Because patients do not inform hospital staff of their intent to leave, there is no chance to discuss the risks of leaving and benefits of remaining in the hospital for treatment. Elopement is different from wandering, which is used to describe when a patient strays beyond the view or control of staff without the intent of leaving (often because of cognitive impairment).

If a patient elopes, you should document the date and time that you were informed of the elopement as well as who notified you. The documentation should contain only facts and not speculation on why the patient eloped. A discharge summary is still required. In the disposition part of the discharge summary, state that the patient eloped. An elopement prevents the patient from receiving specific discharge instructions and follow-up care information, and it is customary to document that you were unable to provide this information to the patient.

Suppose that Mr. Sanford, the patient mentioned in Example 12.2, had eloped rather than telling the staff that he was leaving AMA. Once the staff discovered the elopement and informed the physician, this was documented in the patient’s medical record as shown in Example 12.3.

EXAMPLE 12.3

xx/xx/xxxx, 1948. I received a call from Karen Macayo, head nurse of telemetr y 5B unit, regarding Mr. San- ford. The nurse who was assigned to care for him was making rounds when she fir st came on shift and noticed that Mr. Sanford was not in his room. His IV had been disconnected, and the tubing was lying on the bed. The IV catheter was still attached, and a small pool of blood was noted on the bedding. The oxygen tubing was found on the bedside table . A hospital gown was found on the bed. The nurse checked the imaging schedule to be sure that the patient was not in that depar tment; no imaging studies had been or- dered for Mr. Sanford, and a call to the depar tment

confirmed that he was not there. Nursing staff stated that Mr. Sanford had not indicated to them that he was planning to leave. Several overhead pages asking Mr. Sanford to return to his room were made without success. Security was notified, and they checked the hospital grounds. Mr. Sanford was not found and is presumed to have eloped.

Signature of attending physician

Summary As a health-care provider, you should be aware of clinical and nonclinical factors that increase a patient’s risk for re-admission, and you should weigh all these factors carefully when deciding that a patient is ready for dis- charge. Once the patient is deemed ready for discharge, specific orders are required. In addition to the Admission History and Physical, the Discharge Summary is one of the most important documents that will be gener- ated during a patient’s hospitalization. This summary should communicate important events of the patient’s hospital stay, including admitting problem, response to treatment, and development of any new problems as well as the management of those problems. The medication reconciliation done at the time of discharge is extremely important and should ensure that patients know exactly which of their prehospital medications to continue and which, if any, should be discontinued. The medication reconciliation also should detail any new medications prescribed, why prescribed, and how long the medication should be taken. At the time of discharge, you should provide the patient with specific information related to care at home, follow-up appointments, and diet and activity. Also, you should educate patients about any symptoms that they should report to you or another health-care provider. Provide written discharge instruc- tions to the patient or caregiver, in the patient’s preferred language, so that the patient can review the information after discharge. To reinforce the content of this chapter, please complete the worksheets that follow. And be sure to review Appendix A, the Document Library, for full case examples of patient documentation.

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Worksheet 12.1

Name: ��

Discharge Orders and Discharge Summary

1. List three clinical risk factors associated with re-admission within 30 days of discharge.

2. List four nonclinical risk factors associated with re-admission within 30 days of discharge.

3. List three components of the discharge orders.

4. List three components that should be addressed when instructing a patient on activity at the time of a

hospital discharge.

5. List at least seven components of a discharge summary.

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6. List at least three entities that may ask for (or are likely to receive a copy of) the discharge summary.

7. List at least three diagnoses for patients who are most likely to leave a hospital AMA.

8. List at least three elements that should be included in an AMA note.

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Worksheet 12.2

Name: ��

Discharge Summary for R.H.

Read the discharge summary for R.H., an 84-year-old man who is being transferred to a psychiatric facility upon

discharge from the hospital. Based on the discharge summary, answer the questions that follow.

Discharge Summary—R.H.

PATIENT: R.H. MR#: 427-08-733

SEX: Male DOB: 05/17/XXXX

DATE OF ADMISSION: 03/22/XXXX

DATE OF DISCHARGE: 04/01/XXXX

DISCHARGE DIAGNOSES: 1. Chest pain. No MI. 2. Right hip fracture due to fall in hospital, s/p ORIF. 3. Right fifth metacarpal fracture. 4. CAD with prior stents. 5. Paroxysmal atrial fibrillation. 6. Diabetes mellitus, type 2. 7. Acute renal failure, resolved. 8. Mild abnormality of liver enzymes, history of chronic hepatitis B. 9. Malnutrition. 10. UTI, treated. 11. Encephalopathy with acute illness postoperative delirium in addition to dementia.

ATTENDING PHYSICIAN: Reginald Dykstra, MD

Consulting Physicians: Connor Everett, DO; Cardiology Burton Samuelson, MD; Neurology Wayne Billingsly, MD; Orthopedics Edward Dobrison, MD; Psychiatry

For details of the presenting history and physical examination, please refer to the H&P in the chart.

Hospital Course: In brief, the patient is an 84-year-old man. He was initially admitted from the emergency department with complaint of chest pain. He had a history of CAD and prior stents. An MI was ruled out with serial enzymes. He did have some paroxysmal atrial fibrillation, then stayed in sinus rhythm. He was seen during the hospitalization by Dr. Everett from Cardiology. The first night of admission, the patient got up unassisted owing to confusion, fell, and had a fracture of the right hip. He was treated by Dr. Billingsly for orthopedic surgery. He also had some acute renal failure when he came in the hospital probably due to dehydration; this returned to normal. The patient underwent ORIF of the hip. He had no further chest pains. His diabetes was monitored and covered. He was seen by Dr. Samuelson for Neurology and Dr. Dobrison for Psychiatry. He was quite agitated and assaultive at times. They were managing him with medications and recommended an inpatient psychiatry unit. The patient will be transferred to an inpatient psychiatric facility when a bed is available. His condition is improved and stable at time of transfer. Prognosis is fair.

Medications: Risperidone 1 mg three times a day; Levaquin 250 mg daily; Lactulose twice daily; thiamine 100 mg a day; nitroglycerin ointment 2%, 1 inch every 6 hours; metoprolol 50 mg orally twice a day; enoxaparin 80 mg subcutaneous daily; and multivitamin once a day. He is on sliding scale insulin. He will be up as directed by physical therapy. He will be on his heart-healthy diabetic diet.

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1. How long was R.H. in the hospital?

2. Which discharge diagnoses listed are not addressed in the narrative of the hospital course?

3. R.H. will be transferred to a psychiatric facility. If you were a provider at the receiving facility, what criticisms

would you have of this discharge summary?

4. What findings support that R.H. is ready for discharge from the hospital?

5. Refer to Figure 12-2, Discharge Summary for Mr. Jensen. Identify at least three elements included in that

discharge summary that are not included in R.H.’s discharge summary.

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Worksheet 12.3

Name: ��

Discharge Summary for H.O.

Read the discharge summary for H.O., a 53-year-old man who was hospitalized for orthopedic surgery. Based

on the discharge summary, answer the questions that follow.

Discharge Summary for H.O.

PATIENT: H.O. MR#: 441-07-638

SEX: Male DOB: 10/25/XXXX

DATE OF ADMISSION: 07/14/XXXX

DATE OF DISCHARGE: 07/18/XXXX

ADMITTING DIAGNOSIS: Quadriceps tendon rupture of the right knee s/p prior total knee arthroplasty.

DISCHARGE DIAGNOSIS: Quadriceps tendon rupture of the right knee s/p prior total knee arthroplasty.

ATTENDING PHYSICIAN: Richard Lyons, MD

PRIMARY CARE PHYSICIAN: Melinda Knowles, DO

HOSPITAL COURSE: The patient was admitted on 07/14/XXXX after he was noted to have an extensor mechanism rupture. He presented to the ED initially. Internal Medicine was consulted for medical optimization and clearance. On 07/15/XXXX, he was taken to the OR, where he underwent a quadricepsplasty of the right leg for apparent augmentation of the quadriceps rupture with allograft augmentation, a lateral release, and an anterior synovectomy. The patient tolerated the procedure well. He was placed in a long-leg bulky Robert Jones dressing. He was admitted to the orthopedic unit and was allowed weight-bearing as tolerated in the splint. He had daily physical therapy. Intra-operative cultures were obtained. Initial Gram stain was negative. Final cultures were negative at 72 hours. On POD #2, the patient’s hemoglobin dropped to 9.0, and he was transfused with 2 units packed RBCs. He was noted to have decreased magnesium and potassium, which were replaced. On POD #3, the patient was able to ambulate 200 feet with physical therapy and was stable for discharge home.

CONDITION ON DISCHARGE: Stable

DIET: Regular

DISCHARGE MEDICATIONS: 1. Colace 100 mg bid 2. Ferrous sulfate 325 mg bid 3. Aspirin 325 mg bid 4. Multivitamin daily 5. Tramadol 50 mg every 6 hours

DISCHARGE INSTRUCTIONS: The patient is discharged home. He will be weight-bearing as tolerated in the splint. He will present next week to be placed in a long-leg cast. He will remain on aspirin therapy for 6 weeks for DVT prophylaxis. All questions were answered and discussed, and the patient is agreeable.

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1. What complications developed postoperatively that are not listed as discharge diagnoses?

2. If you were Dr. Knowles, the patient’s primary care provider, what information would you like to know that

is not included in this discharge summary?

3. What type of culture was obtained, and what is the significance of the results reported in the discharge

summary?

4. What findings support that H.O. is ready for discharge from the hospital?

5. What specific information is missing from the discharge instruction section of the summary?

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Worksheet 12.4

Name: ��

Discharge Summary for G.M.

Refer back to the admission H&P in Figure 10-11 for G.M. Read the daily progress notes that follow and use

the information to write a discharge summary.

HOSPITAL DAY #1, 0920

S: G.M. states that she did not sleep well last night. She attributes this to noise from the hallway. She specifically

denies having any chest pain or pressure. She did ambulate 2 or 3 times yesterday with minimal dizziness.

She denies any dizziness at the present time. She has not experienced any SOB. She does not have any new

complaints.

O: A&O × 3. VS: BP 116/68, P 103, R 16. Neck: no JVD. Heart: rhythm still irregular. 2/6 systolic murmur;

unchanged. Lungs: clear to auscultation all fields. Ext: no peripheral edema. IV Cardizem infusing. Serial troponin

levels have remained WNL. Serial ECGs show persistence of atrial fibrillation but no ischemic patterns. She

received the Lantus dose this morning, 22 units. She has been on sliding-scale insulin also. Max blood glucose

of 402 last evening, and she was covered with 10 units of regular insulin. Accu-Chek this morning was 385,

and she received 8 units regular insulin. Cardiology consult appreciated; note reviewed and agree with starting

patient on metoprolol. Wait another 24 hours to see if patient’s rhythm will be restored to NSR.

A: (1) Atrial fibrillation. (2) Chest pain resolved; MI ruled out. (3) Hypertension. (4) Uncontrolled diabetes.

(5) UTI.

P: Will continue IV Cardizem. Start metoprolol 50 mg PO bid. Will wait on starting back on lisinopril because

the beta blocker will be started. Continue sliding-scale insulin. Consider endocrinology consult if not within

acceptable range in another 24 hours. Add Cipro 500 mg PO bid for 7 days.

HOSPITAL DAY #2, 0745

S: Doing well. States no dizziness in the past 24 hours. Specifically denies chest pain.

O: A&O × 3. VS: BP 132/84, P 92, R 18. No JVD. Heart rate slower today and now regular. Remainder of

physical exam unchanged. ECG shows NSR with rate of 94. BP up over the past 24 hours at all readings.

Blood glucose range of 240–380 over past 24 hours. Still receiving sliding-scale insulin per routine doses.

Urine culture was positive for greater than100,000 colonies E. coli.

A: (1) Atrial fibrillation resolved, now with NSR. (2) Hypertension with persistently elevated readings over past

24 hours. (3) Uncontrolled diabetes. (4) UTI with positive cultures.

P: Discontinue IV Cardizem. Restart lisinopril 5 mg PO daily. Continue with sliding-scale insulin per routine

orders. Continue Cipro and all other regular medications.

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HOSPITAL DAY #3, 0820

S: Patient says she did not sleep well again last night. Specifically denies any chest pain or pressure or SOB. At-

tributes not sleeping well to being away from home and in a different environment. She is ambulating with

assistance. No further dizziness or lightheadedness. Appetite is improving.

O: A&O × 3. BP 126/84, P 88, R 16. Heart rate regular. Breath sounds clear. No change in exam. Telemetry

strips reviewed; patient with mostly sinus rhythm over the past 24 hours. She did have a few runs of atrial fib

but remained asymptomatic. Blood glucose range 160–230. She is requiring less sliding-scale insulin coverage.

Continues on Cipro for UTI.

A: (1) Atrial fibrillation mostly resolved; doing well on metoprolol. (2) Hypertension; stable. (3) Type 2 diabetes;

glucose control improving but not yet at goal. (4) UTI; currently being treated.

P: Continue present management. Social services to consult for discharge planning.

HOSPITAL DAY #4, 0750

S: Patient without any complaints. Has not had any further episodes of dizziness or lightheadedness. Denies

SOB. Ambulating without difficulty. Nurse reports that patient slept through the night. Social services note

reviewed; patient has daughter who can stay with her for a few days.

O: A&O × 3. BP 134/80, P 90, R 16. Heart RRR, systolic murmur 2/6. Lungs clear all fields. No peripheral

edema. All recorded blood pressures in acceptable range of less than130 systolic and less than 80 diastolic.

Blood glucose range 140s to 180s. Has only required 2 interval doses of insulin in the past 24 hours.

A: (1) Atrial fib; converted and maintaining NSR on metoprolol. (2) Hypertension; stable. (3) Type 2 diabetes;

better control now that UTI is resolving.

P: Continue metoprolol and present management. If glucose stays within normal range without sliding-scale

coverage, anticipate discharge tomorrow.

HOSPITAL DAY #5, 0900

S: Patient denies any chest pain or pressure, dizziness, or SOB. Feels like she is ready to go home.

O: A&O × 3. All vital signs have been within normal range for the past 24 hours. Blood glucose max was 144.

Patient did not require any sliding-scale doses in past 24 hours. Heart RRR, 2/6 systolic murmur. Lungs clear.

Abdomen soft with bowel sounds throughout. No CVA tenderness. No peripheral edema.

A: (1) Atrial fib, controlled on metoprolol. (2) MI ruled out; no further chest pain. (3) Hypertension, stable on

lisinopril. (4) Type 2 diabetes, stable on regular dose of Lantus. (5) Resolving UTI.

P: Patient asymptomatic now. Ambulating without difficulty. No recurrence of chest pain or dizziness. Stable

for discharge to home. Will continue her on metoprolol 50 mg PO bid. Continue Cipro 500 mg PO bid for

2 more days. Continue Lantus 22 units daily in a.m. Continue all other regular home medications. Patient

should not drive for 2 weeks, until she has had time to adjust to all medications. Otherwise, activity as toler-

ated. Continue on 1,800-calorie ADA, heart-healthy diet. Notify Dr. Rosenberg immediately of any episodes

of chest pain or pressure, dizziness, or any new symptoms. Otherwise, follow up with Dr. Rosenberg in 1

week. Follow up with cardiologist in 2 weeks. Discharge instructions discussed with patient and daughter. All

questions answered. Patient is agreeable to discharge.

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Discharge Summary

• Date of admission

• Date of discharge

• Admitting diagnosis (or diagnoses)

• Discharge diagnosis (or diagnoses)

• Attending physician

• Primary provider and consulting physician(s) (if any)

• Procedures (if any)

• Brief history, pertinent physical examination findings, and pertinent laboratory values (at time of admission)

• Hospital course

• Condition at discharge

• Disposition

• Discharge medications

• Discharge instructions and follow-up instructions

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Worksheet 12.5

Name: ��

Discharge Orders for G.M.

Based on the discharge summary written for Worksheet 12.4, write corresponding discharge orders for G.M.

• Disposition (where the patient will go after discharge from the hospital)

• Activity with specific instructions

• Diet

• Medication reconciliation, including prehospital medications that should be resumed or stopped as well as any

new medications

• Follow-up instructions (who and when)

• Notification instructions (signs or symptoms that could signal complications)

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Worksheet 12.6

Name: ��

Abbreviations

These abbreviations were introduced in Chapter 12. Beside each, write the meaning as indicated by the

context of the chapter.

AMA ��

H&H ��

PCP ��

CEA ��

H&P ��

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309

Document Library

Now that you are familiar with the process of documentation, you can review some patient files. In the following pages you will find the pertinent documents for a number of patients, including SOAP notes, consult notes, and notes for hospice and palliative care, so that you can follow each patient’s episode of care from start to finish.

Appendix A

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310 | Appendix A

Patient: M.S. The next five documents pertain to patient M.S., a 73-year-old man admitted for inpatient care. The first document is the admission History and Physical Examination by the hospitalist, Dr. Daniel Krackov. Following are consul- tation notes from four different specialties (gastroenterology, cardiology, neurology, and orthopedics) that address various problems that arise during M.S.’s hospital stay.

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Appendix A | 311

Patient: M.S. Result Type: ADMISSION HISTORY AND PHYSICAL EXAMINATION Performed by: Daniel Krackov, MD Encounter Info: M.S., 4853105, PUMC, Inpatient Date of Birth: 2/4/19XX

Chief Complaint: Nausea, vomiting, and fall History of Present Illness: M.S. is a 73-year-old man who presented to the emergency department today with a 4-day history of nausea, vom- iting, and an episode of weakness, “almost passing out.” He also had a ground-level fall inside his home yesterday. He stood and became lightheaded and dizzy and fell. He feels like his left leg gave out on him; he denies actually falling on his knee and denies hitting his head or having any loss of consciousness. There was no witness to the fall. There was just this single episode of dizziness and falling. He has had nausea with multiple episodes of vomiting. He thinks the vomiting contributed to the weakness because he has not been holding down any food or fluids for the past 48 hours. He does have a gastroenterologist and has had both EGD and colonoscopy within the past year, which he says were both “normal.” M.S. also had an episode of chest pain on the day prior to admission. He does have chronic-type chest pain, and, per old records, he has had elevated troponins rather chronically. He has had arrhythmia in the past, specifically paroxysmal atrial fibrillation, and he sees a cardiologist as an outpatient. His last stress test was almost 2 years ago. He says this episode of pain lasted about 10 minutes. He was already having N/V, so cannot tell if there was any specific association of these symptoms with the chest pain. He denies shortness of breath and diaphoresis. He has had some cough but also some nasal congestion cold symptoms for almost 1 week. He denies any sick contacts at home. In addition to the above, M.S. has had chronic neck and back pain for 10 years or more and has had multiple orthopedic surgeries in the past. He denies loss of function of any extremities. He has not had any change in ability to speak or swallow.

Allergies: HEPARIN (hives) Review of Systems: General: Weakness, denies fever or chills. No weight loss. Head: Denies headaches, trauma. ENT: Positive for nasal congestion, sinus congestion; otherwise negative. Respiratory: Positive for nonproductive cough for the past week. Denies SOB and any other symptoms. Cardiovascular: Positive for episodic chest pain. Does have a history of elevated troponins. Gastrointestinal: Positive for nausea, vomiting. Denies gross hematemesis but says some “blood streaked”

vomitus. No diarrhea. No tarry stools. Genitourinary: No dysuria or hematuria. Musculoskeletal: Arthritis, chronic neck and back pain. Left knee pain; denies swelling or heat in the left knee.

Denies gouty flares. Neurological: Positive for near-syncope. Denies loss of consciousness, headaches, slurred speech or loss of

function of any extremities. Integumentary: Denies rashes or concerning lesions. Endocrine: Denies heat or cold intolerance. Hematologic: Positive for chronic anemia and prior left lower extremity DVT, about 8 years ago after orthope-

dic surgery. Denies easy bruising. Psychiatric: Positive for PTSD. Denies suicidal thoughts.

Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Paroxysmal atrial fibrillation status post cardioversion × 2 4. Osteoarthritis 5. Post-traumatic stress disorder 6. Hepatic steatosis

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312 | Appendix A

7. Diverticulosis 8. Inguinal hernia, right 9. Chronic back and neck pain

10. Spinal stenosis 11. Gout 12. Glaucoma 13. History of mild cardiac enzyme elevation 14. Esophagitis 15. Chronic chest pain with chronic troponin elevation 16. Gastroesophageal reflux disease

Past Surgical History: 1. Cholecystectomy 2. Cataract extraction, bilaterally 3. Tonsillectomy 4. Lumbar laminectomy 5. Left total hip arthroplasty with revision 6. Left thumb surgery

Family History: Father died of COPD at age 55. Mother is 82, still living with no significant medical history.

Social History: He is single, lives with his girlfriend. Has two grown children. He requires assistance with IADLs. He denies tobacco use, alcohol use, or illicit drugs.

Home Medications: 1. Prazosin 4 mg PO nightly 2. Vitamin B12 1,000 mcg PO daily 3. Colchicine 0.6 mg bid 4. Losartan 50 mg daily 5. Multivitamin 1 pill daily 6. Hydralazine 25 mg PO tid 7. Sotalol 80 mg PO bid 8. Amlodipine 10 mg PO daily 9. Lisinopril 40 mg PO daily

10. Allopurinol 200 mg daily 11. Dorzolamide-timolol ophthalmic 12. Bimatoprost 0.03% ophthalmic 13. Brimonidine 0.2% ophthalmic 14. Saline drops OTC PRN 15. He also takes Medrol Dosepak PRN gouty attack

PHYSICAL EXAMINATION: Vitals: Blood pressure 104/68, O2 saturation 97% on room air; pulse 92, respiratory rate 16, temperature 38.6. General: Pleasant elderly male in moderate distress due to leg pain and nausea. HEENT: Anicteric sclerae. Pupils equally reactive to light and accommodation. Extraocular muscles intact.

Ears clear. Nose with clear rhinorrhea. Oropharynx clear. Neck: Supple, no JVD, no thyromegaly, carotid bruit, and no lymphadenopathy of the cervical or supraclavicu-

lar chain. Respiratory: No labored breathing, coarse breath sounds, scattered rhonchi bilaterally. Cardiovascular: Rate and rhythm regular. Normal S1, S2. No murmur or gallop. Abdomen: Soft, nondistended, no hepatosplenomegaly. Diffusely tender but without guarding. Normal bowel

sounds.

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Appendix A | 313

Extremities: No cyanosis, clubbing, or edema. Obvious tenderness to palpation of the distal thigh on the right side. Neurological: Alert and oriented × 4. Cranial nerves II–XII normal. Motor and sensory examined and the

patient has severe sensory deficit to the right foot, also has reduced motor strength to the right lower extrem- ity. Deep tendon reflexes sluggish to the right side.

Integumentary: No rash. Psychiatric: Appropriate behavior.

LABORATORY DATA: WBC 3.4, hemoglobin 12.3, hematocrit is 36.7, platelet 174, PT 13.2, INR 1.0, PTT 24, glucose 110, BUN 16, creatinine 1.08, sodium 141, potassium 3.7, chloride 103, CO2 24. Cardiac enzymes: CK 48, troponin 0.17, and the patient has history of chronically elevated troponin. Urinalysis negative for urinary tract infection.

IMAGING: EKG by my interpretation with NSR rate of 84 and no ischemic changes. CT of abdomen and pelvis shows some chronic inflammatory changes of the sigmoid colon consistent with diverticulosis but there is no evidence of acute diverticulitis. The appendix appears enlarged but is stable compared to previous CT.

ASSESSMENT AND PLAN: 1. Neurological: Significant radiculopathy to right lower extremity, including motor and sensory deficits. This

may be from lumbar spinal stenosis, but I will consult neurology for further evaluation. He may need an MRI of the lumbar spine. No overt signs of stroke at this time.

2. GI: Multiple episodes of N/V with possible GI bleed, although hemodynamically stable at this time. Pt reports he has had prior colonoscopy and EGD that were “normal.” Due to the persistence of his N/V and possible bleed, I will consult GI.

3. Knee pain: Has had prior hip arthroplasty and revision, now with left knee pain that started before his fall. I will consult orthopedist, Dr. Copeland, who did his last surgery.

4. Chest pain with elevated troponin: This has been chronic but he did have episode of pressure-like chest pain yesterday and has history of atrial fibrillation. I do not think he will need any urgent intervention but will consult Dr. Olsen’s group for cardiology evaluation.

5. Ophthalmology: Glaucoma. He will continue current eye drops. 6. Rheumatology: History of gout. He is on allopurinol and colchicine; we will continue these medications.

Total time with the patient 45 minutes.

Daniel Krackov, MD

Result Type: Consultation Report Performed by: David Paxton, ANP for Dr. Audrey West Encounter Info: M.S., 4853105, PUMC, Inpatient

CONSULTATION REPORT: Service: Gastroenterology Date of Birth: 2/4/19XX Requesting Physician: Daniel Krackov, MD Reason for Consultation: Nausea, vomiting, and diarrhea

History of Present Illness: M.S. is a 73-year-old gentleman well known to our group from prior hospital admissions. He came in through the emergency department complaining of nausea, vomiting, diarrhea, and chest pain. The patient was discharged from a skilled nursing facility recently after a hospital stay. For the past 24 hours, he reports nausea with multiple episodes of vomiting and diarrhea, abdominal pain, and chest pain. The patient reports “specks of blood” some- times mixed with the stools and streaky blood in his emesis. He denies passage of any blood clots. He has had

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314 | Appendix A

a GI workup recently, including EGD and colonoscopy remarkable for erosive esophagitis, a few colon polyps, and hemorrhoids and sigmoid diverticulosis. In the emergency department here, he had a CT angio of the chest, abdomen, and pelvis, concluding no acute abnormality. Liver is enlarged with hepatic steatosis. Normal-appearing pancreas, no changes of chronic pancreatitis described. Appendix is abnormally enlarged in the right lower quadrant measuring 1.3 cm without associated inflammatory changes to suggest appendicitis. This is unchanged from prior imaging study. There are a few colonic diverticula involving the distal ileum, fat-containing right inguinal hernia, extensive atherosclerotic changes throughout the abdominal aorta extending into the iliac vasculature, inferior vena cava filter and subtle wall thickening involving the distal esophagus.

Allergies: HEPARIN (hives) Review of Systems: General: Weakness, chronic pain. Denies fever, chills, weight loss. GI: + Nausea, vomiting, diarrhea with specks of blood in stool and sometimes blood-streaked emesis; other-

wise negative. Musculoskeletal: + Right leg pain, back pain; otherwise negative. Remaining systems reviewed and are negative.

Past Medical History: Multiple medical problems including chronic pain, especially back pain on chronic opioids, CAD with chronic chest pain; A Fib on anticoagulation; esophagitis, hepatic steatosis, prior cholecystectomy; sigmoid diverticulosis, inguinal hernia, hemorrhoids, arthritis, glaucoma, gout, HTN, dyslipidemia.

Family History: Father COPD. Mother also had diverticulosis. Specifically, no hx of gastric or colorectal cancers.

Social History: Lives with his girlfriend of many years. Has primary care provider. Formerly a heavy drinker but quit drinking more than 6 years ago. Denies ever smoking or using illegal drugs.

Home Medications: Sotalol Ranexa Keppra B12 Protonix Prazosin Creon Florastor Morphine Digoxin Amlodipine Carafate Prescription eye drops for glaucoma

PHYSICAL EXAMINATION:

Vitals: Pulse 108, BP 142/65, afebrile. Weight is 93 kg, BMI is 24.46. General: A&O, well developed, converses appropriately, no acute distress. HEENT: Normocephalic. Normal hearing. Sclerae are anicteric. Conjunctivae pink. Mucous membranes moist. Dentures are well fitting and in good repair. Neck: Supple, full ROM. No masses. Respiratory: Clear to auscultation. Cardiovascular: Normal S1, S2 with regular rate and rhythm. Abdomen: Soft. Generalized tenderness but no guarding or rebound tenderness. Bowel sounds present all quadrants.

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Appendix A | 315

LABORATORY DATA: Remarkable for a troponin of 0.68. WBC 3.4, hemoglobin 12.4, platelets 174. All electrolytes are normal. AST 91, total bilirubin 1.2, alk phos 96, lipase 315.

IMAGING: CT angio of the chest, abdomen, and pelvis, concluding no acute abnormality.

ASSESSMENT AND PLAN: 73-year-old man with nausea, vomiting, abdominal pain, and what appears to be insignificant amounts of blood. He had recent GI workup including endoscopy and colonoscopy, findings as noted above. Do not suspect active GI hemorrhage at this time. Chest pain and elevated troponin; cardiology is evaluating. We will start IV PPI. Check serial H&H. Check CRP. We will continue to follow.

Thank you for allowing us to participate in the care of this patient.

David Paxton, ANP

Audrey West, MD

Result Type: Consultation Report Performed by: Adam Olsen, DO Encounter Info: M.S., 4853105, PUMC, Inpatient

CONSULTATION REPORT: Service: Cardiology Date of Birth: 02/04/19XX Requesting Physician: Daniel Krackov, MD Reason for Consultation: Elevated cardiac enzymes

History of Present Illness: M.S. is a 73-year-old who presented to the emergency department at Phoenix University with a 4-day history of nausea, vomiting, and a 1-day history of near-syncopal-type symptoms. The patient reports that 4 days prior to presentation, he began having cold-type symptoms with persistent nausea, vomiting, and diarrhea that lasted for 4 days. The patient reports that on the day of presentation, he became lightheaded and dizzy upon standing. He denies any loss of consciousness but did report that he fell due to severe osteoarthritis of his right knee. Of note, the patient does have a significant past medical history of mildly elevated troponin enzymes and did have a stress test performed approximately a year and a half ago, which was negative. The patient has not ever had a cardiac angiogram performed and, of note, the patient did report that 1 day prior to presentation, he had a 5- to 10-minute episode of chest pain that was described as “a ton of bricks on my chest” with some gastrointestinal gas associated with these symptoms. Cardiology consultation was requested for mildly elevated troponin at 0.17. Of note, this is higher than previous values, which were averaging 0.09 and 0.10. This is an established patient familiar to our practice.

Allergies: HEPARIN (hives) Review of Systems: General: Negative for fevers, chills, fatigue. HEENT: Positive for mild sinus congestion. Negative for visual changes, hearing loss, odynophagia. Neck: Negative for masses or thyromegaly. Cardiovascular: Positive for chest pain; please see HPI. Negative for palpitations or murmurs.

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316 | Appendix A

Gastrointestinal: Positive for nausea, vomiting, diarrhea as per HPI. Genitourinary: Negative for hematuria. Neurological: Positive for near-syncope. Negative for seizures, unilateral weakness, loss of consciousness. Skin: Negative for rashes, lesions, or lacerations. Extremities: Negative for swelling. Musculoskeletal: Positive for right knee osteoarthritis with swelling and pain.

Past Medical History: 1. Hypertension 2. Paroxysmal atrial fibrillation status post cardioversion × 2 3. Osteoarthritis 4. Post-traumatic stress disorder 5. Hyperlipidemia 6. Gout 7. Glaucoma 8. History of mild cardiac enzyme elevation

Family History: Mother with a history of anxiety. Otherwise, no pertinent family history.

Social History: Denies smoking. Quit drinking alcohol approximately 6 years ago. Denies any illicit drug use. Currently with poor functional status given his right OA.

Home Medications: 1. Prazosin 4 mg PO nightly 2. Vitamin B12 1,000 mcg PO daily 3. Hydralazine 25 mg PO tid 4. Sotalol 80 mg PO bid 5. Amlodipine 10 mg PO daily 6. Lisinopril 40 mg PO daily 7. Allopurinol 200 mg daily 8. Dorzolamide-timolol ophthalmic 9. Bimatoprost 0.03% ophthalmic

10. Brimonidine 0.2% 11. Saline drops OTC PRN

PHYSICAL EXAMINATION:

Vitals: Blood pressure 121/86, respiratory rate 16, heart rate 91, oxygen saturation 100% on room air, height 196 cm, weight 102 kg, BMI 26, temperature 36.6 degrees Celsius.

General: Patient is sitting up in bed, pleasant and conversant, alert and oriented × 4, in no acute distress. Co- operative during the exam.

HEENT: Moist oropharynx without exudates or erythema. Pupils equal, round, and reactive to light bilaterally. No scleral injection, normal conjunctivae.

Neck: No masses or carotid bruits appreciated. Normal thyroid size to palpation. Respiratory: No increased respiratory effort. Normal AP diameter. Breath sounds without wheezing or rhon-

chi in all lung fields. Cardiovascular: Heart regular rate and rhythm without murmurs, rubs, or gallop. Normal S1, S2. Abdomen: Slightly hyperactive bowel sounds. Nontender to palpation diffusely. No rebound tenderness. No

hepatosplenomegaly appreciated. Skin: No erythema or induration appreciated around the right knee, however, also no other rashes or lesions

appreciated.

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Appendix A | 317

Extremities: No peripheral pitting edema. Good peripheral pulses in all extremities. Neurological: Cranial nerves II–XII grossly intact without focal neural deficit. Muscle strength 5/5 in bilateral

upper and lower extremities. DTR is intact throughout, 2+. Musculoskeletal: There is tenderness to palpation on the medial and lateral aspects of the right knee with

some effusion. No erythema appreciated. Good range of motion without guarding.

LABORATORY DATA: WBC 3.4, hemoglobin 12.3, hematocrit is 36.7, platelet 174, PT 13.2, INR 1.0, PTT 24, glucose 113, BUN 10, creatinine 1.11, sodium 141, potassium 3.7, chloride 103, CO2 24. Mild AST elevation to 91, CK of 48, troponin of 0.17, UA with some mild proteinuria and increased hyaline casts.

IMAGING:

1. Chest x-ray showed no acute intrapulmonary process. 2. Right x-ray of the knee, 3 view, showed moderate degeneration in the medial compartment and some asso-

ciated soft tissue swelling. 3. EKG showed sinus rhythm at a rate of 92 with normal axis and QRS intervals. There are ST segment de-

pressions in the inferolateral leads consistent with previous EKGs date back to 4/25/2011. No changes from previous EKGs.

ASSESSMENT AND PLAN:

1. Mild cardiac enzyme elevation: Suspect possibly secondary to volume depletion and mild heart strain. However, given that the patient has had persistent mild elevation in his troponin levels for the last year, will consider performing cardiac catheterization if patient is still in-house at the beginning of next week. Otherwise, recom- mend outpatient follow-up and recommend coronary angiography as an outpatient. Trend troponin levels.

2. Suspected viral gastroenteritis: Would recommend that the patient become fluid resuscitated per primary team. No evidence of ischemic cardiomyopathy or other evidence of heart failure warranting fluid restric- tion. Given his volume depletion, would also check a magnesium level and replace as needed.

3. Hypertension: Appears to be well controlled with current medications. Would continue. 4. Hyperlipidemia: Again, would continue current medication. 5. Mild leukopenia: Would follow and trend. 6. Normocytic anemia. 7. Mild AST elevation. 8. Mild proteinuria. 9. Paroxysmal atrial fibrillation. The patient is status post cardioversion ×2 in the past. Would agree with

monitoring the patient on telemetry. 10. Gout: Possibly gout flare in the right knee. Will defer to primary team for management and workup. 11. Post-traumatic stress disorder. 12. Glaucoma: Would continue outpatient medications.

Adam Olsen, DO

Result Type: Consultation Report Performed by: Marjan Caronni, MD Encounter Info: M.S., 4853105, PUMC, Inpatient

CONSULTATION REPORT: Service: Neurology Date of Birth: 2/4/19XX Requesting Physician: Daniel Krackov, MD Reason for Consultation: Lower extremity weakness

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318 | Appendix A

History of Present Illness: Patient is a 73-year-old gentleman with past medical history of multiple chronic medical problems. He has been having chronic chest pain, which worsened. Then he started having weakness in his lower extremities and severe pain in the legs. He is having aches and pains all over including headaches. But now, his focus is on low back pain and pain in the lower extremities. Patient underwent L-spine MRI, which is reading 4-mm disc herniation at T11-12 level. This is causing significant central canal stenosis. However, this was not a dedicated thoracic study. He also has severe right foraminal narrowing on L5-S1 level. Also moderate left-sided neural foramina stenosis at L5-S1 and bilaterally at L4-5.

Allergies: HEPARIN (hives) Review of Systems: Constitutional: Negative. Eye: Negative. Ears/Nose/Mouth/Throat: Negative. Respiratory: Negative. Cardiovascular: Negative. Gastrointestinal: Negative. Genitourinary: Negative. Hematology/Lymphatics: Negative. Endocrine: Negative. Immunologic: Negative. Musculoskeletal: Negative. Integumentary: Negative. Neurological: Negative except as documented in the HPI. Psychiatric: Negative except as documented in the HPI.

Past Medical History: GERD, arthritis, HTN, A fib, glaucoma, cataract, DVT, PE, diverticulitis, PTSD, gout, chest pain. Surgical his- tory includes multiple orthopedic procedures, cataract extraction, tonsillectomy, cardioversion, cholecystectomy.

Family History: Father: Emphysema, COPD.

Social History: Never smoked; never any substance abuse, requires assistance with ADLs, chronic pain, uses walker, elevated toilet seat, bedside commode, shower chair. Lives with girlfriend. PCP Dr. Kennedy.

Home Medications: See home list. Amlodipine 10 mg PO q am Brimonidine ophthalmic drops both eyes, bid Digoxin 125 mcg PO q am Dorzolamide ophthalmic drops both eyes bid Florastor 250 mg PO tid Latanoprost ophthalmic drops both eyes q HS Levetiracetam 500 mg bid MS Contin 30 mg PO q 12 hours Pancrelipase 1 cap PO tid with meals Pantoprazole 40 mg PO bid Prazosin 4 mg PO q HS Ranolazine 500 mg PO bid Sotalol 80 mg PO bid Clonidine 0.1 mg PO q 4 hours PRN blood pressure – see instructions Zofran 4 mg/2 mL IV push q 6 hours PRN nausea and vomiting

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Appendix A | 319

PHYSICAL EXAMINATION: Vitals: Temp 36.8°C, blood pressure 115/87, heart rate 80, respiratory rate 16, SpO2 100%. General: Alert and oriented. HEENT: Normocephalic. Respiratory: Normal rate, normal effort. Cardiovascular: Normal rate, regular rhythm. Abdomen: Soft. Neurological: Alert, oriented. Normal sensory, normal motor function. No focal deficits. Cranial nerves II–XII are grossly intact. PERRL. Brisk pupillary reaction to direct light. Diminished reflexes throughout. Musculoskeletal: Normal range of motion.

LABORATORY DATA: WBC 4.3, RBC 4.17, hemoglobin 12.2, hematocrit 38.1, platelet 136, sodium 138, potassium 3.9, CO2 23, glucose 108, BUN 10, creatinine 1.08, magnesium 2.2, calcium 8.8, albumin 3.8, alkaline phos 11, AST 35, ALT 28, bilirubin total 0.9, APTT 26, INR 1.0, Protime 14.4, CK total 81, troponin-I 0.65.

IMAGING: Chest, portable, single view: No evidence of acute cardiopulmonary disease.

Pelvis: Two-view x-rays with postoperative changes consistent with total left hip arthroplasty. Moderate osteoar- thritic change of right hip is present. No visible pelvic fracture. Degenerative changes and postoperative changes lower lumbar sacral spine is present. Vascular calcification seen within the pelvis. CT head/brain W/O contrast: Diffuse cerebral volume loss. The lateral, third and fourth ventricles are normal in size, shape, and position. No mass, mass effect, acute intracranial hemorrhage, or areas of acute infarction seen. Calvarium intact. Hyperdense material within the right maxillary sinus noted. MRI L Spine W/O contrast: Impression: 1. 4-mm disc herniation at T11/12. Herniated nucleus pulposus. This results in significant central canal stenosis. Axial images were not obtained throughout this region on this lumbar spine study. Recommend repeat MRI of this region with axial images to evaluate for degrees of canal stenosis and any cord compression. 2. Severe right neural foraminal stenosis at L5/S1. 3. Moderate left-sided neural foraminal stenosis at L5/S1 and bilaterally at L4/L5. 4. Degenerative changes seen at L1/L2 stable since prior examination.

ASSESSMENT: 1. Generalized weakness (R53.1) 2. Accidental fall (W19.XXXA) 3. Chronic pain syndrome (G89.4)

PLAN: Patient will undergo MRI of thoracic spine to rule out possibility of spinal cord compression. Further plan based on the results.

Marjan Caronni, MD

Result Type: Consultation Report Performed by: Shannon Dalton, PA-C for Dr. Troy Copeland Encounter Info: M.S., 4853105, PUMC, Inpatient

CONSULTATION REPORT: Service: Orthopedics Date of Birth: 2/4/19XX Requesting Physician: Daniel Krackov, MD Reason for Consultation: Back pain, neck pain, leg pain

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320 | Appendix A

History of Present Illness: M.S. was admitted to the hospital after a syncopal episode and a fall. He has a longstanding history of neck and back pain. He also has pain radiating down his left leg. He has never had any injections. He has had physical therapy at times in the past. The back and neck pain are constant, always present. The radiation down the left leg started about 2 weeks ago and has been constant since then. He denies any recent trauma. He has a history of arthritis and has had multiple orthopedic procedures in the past.

Allergies: HEPARIN (hives) Review of Systems: Denies any fever, chills. Complains of rectal bleeding, which is another thing he is admitted for; syncopal episode, and again chronic neck and back pain for which he takes MS Contin regularly, and now left leg pain.

Past Medical History: HTN, history of GI bleed, atrial fibrillation, elevated troponin levels, spinal stenosis, left total hip arthroplasty at age 66; revision of left hip arthroplasty at age 71, lumbar laminectomy L1-L3 at age 65, cervical vertebral fusion at age 67, lumbar fusion at age 67, left thumb surgery age 58; gout.

Family History: Multiple family members with severe rheumatoid arthritis. Father with COPD. No neuromuscular disorders.

Social History: Lives with fiance; on disability for years.

Home Medications: Allopurinol Sotalol Hydralazine Zosyn Lisinopril

PHYSICAL EXAMINATION: Vitals: Afebrile, VSS. General: Pleasant older gentleman in no acute distress. Musculoskeletal: 5/5 strength in deltoids, biceps, triceps extensors and flexors bilateral upper extremities. Strength is 5/5 quadriceps, tibialis and gastrocnemius, extensor hallucis longus bilaterally. Pain is diffusely lateral and pos- terior thigh of left leg. Neurological: Straight leg raise negative bilaterally. No focal neurological deficits.

IMAGING: CT of cervical spine shows moderate amount of stenosis at C4-C5, C5-C6, C6-C7 and also severe neural foram- inal stenosis at L4-L5. The CT scan of the abdomen and pelvis shows moderate stenosis, lumbar spine at L3-L4, L4-l5, and T3. Also, vacuum disk phenomenon and loss of normal lumbar lordosis.

ASSESSMENT AND PLAN: A 73-year-old man with multiple medical problems status post syncopal episode and fall. He has significant de- generative disease and stenosis in the cervical and lumbar spine. At this point in time, we will have him treated with some oral steroids and medicines for pain and mobilization. The patient could be a surgical candidate in the future but not at this time. He could be considered for epidural injections.

Shannon Dalton, PA-C

Troy Copeland, MD

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Appendix A | 321

Patient: H.B. The next document is an intake evaluation form for an outpatient who is being assessed for hospice care to address chronic pain issues.

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322 | Appendix A

Patient: H.B. A/O X 3

PMHX: SHINGLES AND INOPERATIVE KIDNEY STONES, GLAUCOMA, TREMORS. PATIENT HAS NOT BEEN ABLE TO GET FULL PAIN RELIEF FROM SHINGLES/KIDNEY STONES. PAIN IS HER PRIMARY COMPLAINT.

OTHER SIGNS OF DECLINE: WT LOSS 20 LB IN 6 MONTHS, DECREASED APPETITE, AND INCREASED WEAKNESS/SLEEPING.

CODE STATUS: FULL CODE

ANTICIPATE SHORT LENGTH OF STAY PATIENT: NO

PRIMARY HOSPICE DIAGNOSIS: NONDISEASE SPECIFIC (OTHER)

THE PATIENT SHOULD MEET MANY OF THE FOLLOWING NONDISEASE SPECIFIC CRI- TERIA (MARK ALL THAT APPLY):

RECENT DECLINE IN FUNCTIONAL STATUS

INDICATE RECENT DECLINE IN FUNCTIONAL STATUS (MARK ALL THAT APPLY): PALLIATIVE PERFORMANCE SCALE (PPS) SCORE OF 70% OR LESS (SEE OPTIONAL VITAL

SIGNS)

NEED FOR GIP IS THIS VISIT ROUTINE OR GIP? ROUTINE

IS THE PATIENT BEING TRANSPORTED AT TIME OF ADMISSION? NO

HEALTH HISTORY CPR PREFERENCE: WAS THE PATIENT/RESPONSIBLE PARTY ASKED ABOUT PREFERENCE REGARDING THE USE OF CARDIOPULMONARY RESUSCITATION (CPR)? (SELECT THE MOST ACCURATE RESPONSE)

1. YES, AND DISCUSSION OCCURRED

DATE THE PATIENT/RESPONSIBLE PARTY WAS FIRST ASKED ABOUT PREFERENCE RE- GARDING THE USE OF CPR:

6/5/20XX

WAS THE PATIENT/RESPONSIBLE PARTY ASKED ABOUT PREFERENCES REGARDING LIFE-SUSTAINING TREATMENTS OTHER THAN CPR? (SELECT THE MOST ACCURATE RESPONSE)

1. YES, AND DISCUSSION OCCURRED

DATE THE PATIENT/RESPONSIBLE PARTY WAS FIRST ASKED ABOUT PREFERENCES RE- GARDING LIFE-SUSTAINING TREATMENTS OTHER THAN CPR:

6/5/20XX

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Appendix A | 323

WAS THE PATIENT/RESPONSIBLE PARTY ASKED ABOUT PREFERENCE REGARDING HOS- PITALIZATION? (SELECT THE MOST ACCURATE RESPONSE)

1. YES, AND DISCUSSION OCCURRED

DATE THE PATIENT/RESPONSIBLE PARTY WAS FIRST ASKED ABOUT PREFERENCE RE- GARDING HOSPITALIZATION:

6/5/20XX

DISCUSSION OF PATIENT’S PREFERENCES REGARDING LIFE-SUSTAINING TREATMENTS AND HOSPITALIZATION (MARK ALL THAT APPLY):

TREATMENT PREFERENCES CONFIRMED WITH PATIENT

HOSPITALIZATION PREFERENCES CONFIRMED WITH PATIENT

DOES THE PATIENT HAVE DOCUMENTED ADVANCE DIRECTIVES? YES

DID THE HOSPICE OBTAIN A COPY OF ADVANCE DIRECTIVES FOR THE MEDICAL RECORD? NO

WHY WAS A COPY OF THE PATIENT’S ADVANCE DIRECTIVES NOT OBTAINED FOR THE CHART?

MSW TO OBTAIN

HAS THE PATIENT BEEN RECENTLY HOSPITALIZED? NO

PAIN WAS THE PATIENT SCREENED FOR PAIN?

1. YES

DATE OF THE FIRST SCREENING FOR PAIN: 6/5/20XX

THE PATIENT’S PAIN SEVERITY WAS: 1. MILD

TYPE OF STANDARDIZED PAIN TOOL USED: 1. NUMERIC

PAIN SCORE (0–10): 2

PATIENT REPORTED GOAL PAIN SCORE (0–10): 0

WAS A COMPREHENSIVE PAIN ASSESSMENT DONE? 1. YES

DATE OF COMPREHENSIVE PAIN ASSESSMENT: 6/5/20XX

ASSESSING LOCATION? 1. YES

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324 | Appendix A

INDICATE LOCATION OF PAIN (MARK ALL THAT APPLY): ABDOMEN

ASSESSING SEVERITY? 1. YES

SEE RESPONSE TO PATIENT’S PAIN SEVERITY: OK

ASSESSING CHARACTER? 1. YES

HOW DOES THE PATIENT DESCRIBE THE CHARACTER OF PAIN? (MARK ALL THAT APPLY) BURNING THROBBING

ASSESSING DURATION? 1. YES

INDICATE DURATION OF PATIENT’S PAIN: INTERMITTENT

ASSESSING FREQUENCY? 1. YES

FREQUENCY OF PAIN INTERFERING WITH PATIENT’S ACTIVITY OR MOVEMENT: ALL OF THE TIME

ASSESSING WHAT RELIEVES/WORSENS PAIN? 1. YES

INDICATE WHAT RELIEVES PAIN (MARK ALL THAT APPLY): MEDICATIONS TIME OF DAY

INDICATE WHAT MAKES PAIN WORSE (MARK ALL THAT APPLY): OTHER (SPECIFY)

INDICATE OTHER FACTOR THAT MAKES PAIN WORSE: UNKNOWN

ASSESSING THE EFFECT ON FUNCTION OR QUALITY OF LIFE? 1. YES

INDICATE EFFECTS OF THE PAIN ON QUALITY OF LIFE INDICATORS (MARK ALL THAT APPLY):

ABILITY TO ENJOY ACTIVITIES/HOBBIES APPETITE FUNCTIONAL STATUS SLEEP/REST DISTURBANCE

IS PAIN AN ACTIVE PROBLEM FOR THE PATIENT? 1. YES

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Appendix A | 325

INTEGUMENTARY INTEGUMENTARY ASSESSMENT FINDINGS (MARK ALL THAT APPLY):

NO PROBLEMS IDENTIFIED

RESPIRATORY WAS THE PATIENT SCREENED FOR SHORTNESS OF BREATH?

1. YES

DATE OF FIRST SCREENING FOR SHORTNESS OF BREATH: 6/5/20XX

DID THE SCREENING INDICATE THE PATIENT HAD SHORTNESS OF BREATH? 0. NO

GASTROINTESTINAL WAS A SCHEDULED OPIOID INITIATED OR CONTINUED?

0. NO

WAS A PRN OPIOID INITIATED OR CONTINUED? 0. NO

WAS A BOWEL REGIMEN INITIATED OR CONTINUED? (SELECT THE MOST ACCURATE RESPONSE)

2. YES

DATE BOWEL REGIMEN INITIATED OR CONTINUED: 6/5/20XX

INDICATE DATE OF LAST BM: 6/4/20XX

EQUIPMENT/SUPPLIES EXISTING EQUIPMENT/SUPPLIES CURRENTLY PRESENT IN HOME (MARK ALL THAT APPLY):

CANE (QUAD)

IS OXYGEN SAFELY STORED? N/A - NOT APPLICABLE

SOCIAL SUPPORT WAS THE PATIENT/CAREGIVER ASKED ABOUT SPIRITUAL/EXISTENTIAL CONCERNS? (SELECT THE MOST ACCURATE RESPONSE)

1. YES, AND DISCUSSION OCCURRED

DATE THE PATIENT AND/OR CAREGIVER WAS FIRST ASKED ABOUT SPIRITUAL/ EXISTENTIAL CONCERNS:

6/5/20XX

DOES THE PATIENT REPORT DEPRESSION? NO

ARE THERE UNSECURED WEAPONS IN THE HOME? UNKNOWN

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326 | Appendix A

LABS ARE LABS TO BE PERFORMED THIS VISIT?

FALLS HAS THE PATIENT HAD A RECENT FALL?

COMMUNITY PHYSICIAN INFORMATION DOES THE PATIENT HAVE A PCP?

YES

INDICATE FULL NAME/LOCATION: ANDREW GALLOWAYES NAVARRA W 82ND ST STE B

DOES THE PATIENT HAVE A SPECIALIST RELATED TO THE TERMINAL DIAGNOSIS? YES

INDICATE FULL NAME/LOCATION: QUON CHEN, MD, UROLOGIST

LIST ALL OTHER PHYSICIANS (FULL NAME/LOCATION) INVOLVED IN THE PATIENT’S CARE: N/A

PATIENT/FAMILY PREFERENCE FOR FOLLOWING/ATTENDING: MITCHELL KRAUSE

FINANCIAL PAYOR INFORMATION (CHECK ALL THAT APPLY):

X. UNKNOWN

INTERVENTIONS PROVIDED 1. INSTRUCT IN AGENCY CONTACTS AND PHONE NUMBERS.

DETAILS/COMMENTS: FOLDER LEFT IN HOME 2. DISCUSSED PROPOSED PLAN OF CARE AND DISCIPLINES WITH PATIENT/CARE-

GIVER(S) AND (IF APPLICABLE) FACILITY STAFF. DETAILS/COMMENTS: REVIEWED TEAM CONCEPT

3. PROVIDED AGENCY INFORMATION/MATERIALS. DETAILS/COMMENTS: FOLDER LEFT IN HOME

4. INSTRUCTED REGARDING ANY URINARY SYMPTOMS AND ANY IMMEDIATE CARE REQUIRED. DETAILS/COMMENTS: INSTRUCTED TO CALL OFFICE WITH ANY ISSUES

5. INSTRUCTED REGARDING PAIN RELIEF MEASURES AND/OR MEDICATIONS. DETAILS/COMMENTS: INSTRUCTED SISTER REBECCA ON NEW PREDNISONE ORDER

6. INSTRUCTED REGARDING BASIC NUTRITION/HYDRATION FOR THE TERMINALLY ILL PATIENT. DETAILS/COMMENTS: INSTRUCTED TO TRY AND HYDRATE OFTEN

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Appendix A | 327

Patient: R.C. The next document is a palliative care consult for an inpatient who has relapsing lymphoma.

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328 | Appendix A

Patient: R.C. Palliative Care Initial Consult Patient: R.C. Age: 44 years MRN: 82407 Requesting Provider: Dr. Amini

Reason for Consultation: Goals of care in the setting of relapsed, refractory lymphoma Date of Service: 9/27/20XX Interpreter: Rebeca, ID # 4452

Chief Complaint: Fatigue

History of Present Illness: R.C. is a delightful 44-year-old man who was admitted on 9/24/20XX with severe constipation. He had not had BM for 8 days. A CT of his chest showed bilateral pleural effusions and a CT of the abdomen showed moderate fecal load with no obstruction. He had marked ascites. He has a history of relapsed and refractory stage IVB diffuse large B-cell lymphomas and was on MERCK checkmate-155; completed C2D1 on 9/18. He is S/P R-CHOP × 6 but he relapsed within 2–3 months of completing R-CHOP. S/P ICE × 3 (March 20XX), S/P HyperCVAD/MTX × 2 (May, June 20XX), and S/Pd Gem/oxaliplatin/rituximab × 1 ( July 27, 20XX). He was recently hospitalized from 8/26 to 9/4 for pleural effusions and SVC syndrome, and again from 9/15 to 9/20 for tumor lysis syndrome and bilateral pleural effusions. Palliative medicine was consulted to assist with goals of care.

Social History: Tobacco: None ETOH use: None Drug use: None From: California Lives with: Wife Family: Wife has 2 children from a previous relationship. He has no children. Uncles and aunts and many

family members nearby Enjoys: Currently is trying to work on recovery Work: Maintenance Spiritual/religious background: Catholic, likes to attend Mass when he can

Family History: No history of cancer

Past Medical History: Lymphoma, diffuse large B-cell Lymphoma, non-Hodgkin Pleural effusion DVT No known allergies

Home Medications: Acyclovir 400 mg PO bid Allopurinol 300 mg PO daily Bactrim DS 1 tab PO q MWF MiraLax 17 gram PO bid

Review of Systems: Pain: Denies Dyspnea: Denies; has dry cough

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Appendix A | 329

Nausea: Denies Appetite: “Just fine.” He has managed to regain some weight over the last month Bowel/bladder: Was severely constipated but now having BMs Activity: Ambulatory and independent with ADLs Sleep: Sleeping well Mood: Denies anxiety or depression. C/O fatigue

PHYSICAL EXAMINATION: Vital Signs: T 37.7°C (99.9°F), BP 103/70, heart rate 142, respiratory rate 18, SpO2 98% room air. General: Alert and oriented, no acute distress. Respiratory: Respirations are nonlabored. Breath sounds are equal. Symmetrical chest wall expansion. Cardiovascular: Tachycardia, regular rhythm. No edema. Gastrointestinal: Soft, nontender, minimal abdominal ascites. Normal bowel sounds. Musculoskeletal: No tenderness, no swelling, no deformity, moves all 4 extremities spontaneously. Integumentary: Warm, no lesions, no skin breakdown. Neurological: Alert, oriented. No focal deficits. Psychiatric: Cooperative. Appropriate mood and affect.

Labs: CBC WBC 3.3 RBC 3.03 HGB 8.7 HCT 26.3 MCHC 35.0 MCV 87 Platelet 57

BMP Sodium 133 Potassium 4.0 Chloride 100 CO2 16 Glucose 54 BUN 14 Creatinine 0.4

Other Calcium 7.0 Albumin 3.1 Alk Phos 75 AST 80 ALT 25 Bilirubin 1.4

Cardiac Enzymes Troponin-1 less than 0.02

Radiology Results: Chest Single-View Adult Portable Impression: Small bilateral pleural effusions and mild interstitial pulmonary edema have increased when compared to previous film. Lingular and left lower lobe consolidation are unchanged, accounting for differences in lung volumes, which could represent atelectasis or acute air space disease. No other change in the interim since previous study.

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330 | Appendix A

Ultrasound: US Thoracentesis W/Imag Rt Findings: Ultrasound guided right thoracentesis requested. Procedure, benefits, and risks were explained to the patient. Consent obtained. An adequate pocket of fluid was identified in the right hemithorax. Skin was prepped and draped in usual sterile fashion. 2% lidocaine was used for superficial anesthesia. Under direct ultrasound guid- ance a 5 French Yueh catheter was introduced and 1,200 mL of serosanguineous fluid was obtained. Technically successful ultrasound guided right thoracentesis. Patient tolerated procedure well without complication and was returned to the ward in stable condition.

US Ven Duplex Upper Extrem Lt Findings: Left upper-extremity venous Doppler exam with color Doppler imaging and spectral waveform analysis. Occlusive deep venous thrombosis seen within the left axillary and left brachial veins. Superficial thrombophlebitis left cephalic vein above the elbow and left antecubital vein. Enlarged heterogeneous lymph nodes seen in the left neck measuring 4.8 × 3.2 × 4.4 cm and left axillary region measuring 6.6 × 4.0 × 5.7 cm. Known history of lymphoma. Impression: findings as above. Report called the patient’s nurse at 2:47 pm.

Problem List: 1. Constipation 2. Fatigue, cancer associated 3. Dry cough; likely secondary to malignant pleural effusions, recurrent 4. Relapsed and refractory stage IVB diffuse large B-cell lymphoma

Goals of Care: This patient has a condition that is life limiting. This case involves complex medical decision-making, including utilization of medications that require close monitoring for toxicity, and discussions about the burdens of resusci- tation efforts and life-sustaining measures (code status). Additionally, at least 20 minutes were spent in discussions about advance care planning and goals of care.

Plan:

1. Physical aspects of care: Constipation: Severe. Recommend Miralax 1 packet daily and Senna 2 tabs bid. Working well.

Pleural effusions: Would recommend pleur-X catheter when okay with hem/onc.

2. Psychological aspects of care: No depression or anxiety. No needs identified. The patient is at risk for delirium due to the hospital environment, acute illness. Recommend nonpharmacological measures as first line including lights on, shades open, TV off, frequent reorientation during the day, and interruptions minimized at night. If pharmacological intervention for agitation is required, would recommend Haldol 0.5 mg IV q 6 hours PRN.

3. Social aspects of care: No needs identified—appears to have an excellent social support system.

4. Spiritual aspects of care: Catholic. I would recommend involvement of hospital chaplaincy.

5. Advance care planning: Advance directives: has not filled one out. Recommend SW assistance to complete. Names his wife, E.C., as who he would want as MPOA; is his surrogate.

Code status: Full code.

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Appendix A | 331

6. Goals of care: Goals of care were discussed today with R.C. with assistance of an interpreter. He states that he hopes to continue fighting his cancer. He states that he feels like the treatments “are not too bad” and he would want to continue treatments as long as he feels well. His hope is to try a clinical trial at University Hospital in Tucson. He hopes to become well enough to resume working. Goals are consistent with disease directed therapy.

Disposition: home.

Case discussed today with: RN, Dr. Amini.

Face-to-face time spent greater than 30 minutes, greater than 50% of time was spent in counseling and coordination of care. Interdisciplinary team members were present and participated.

Thank you for this interesting consultation. Please call with questions or concerns.

NEZAR BRUNELLI, MD

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332 | Appendix A

Patient: S.L. The next document is a psychiatric consult note on a hospitalized patient who has acute anxiety.

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Appendix A | 333

Patient: S.L. Result Type: Consultation Report Performed by: AnaMaria Ricardo, APRN Encounter Info: S.L., MRN 45217, Inpatient Medical

CONSULTATION REPORT: Service: Psychiatry Date of Birth: 3/24/19XX Requesting Physician: Dr. Reddy Reason for Consultation: Anxiety

History of Present Illness: This is a 55-year-old man who presents with generalized weakness × 3–4 days with recurrent urinary tract infection and with chronic decubitus wound/ulcer of the right buttock with osteomyelitis. While in the hospital, the patient is very anxious. Psychiatry was consulted to assist with diagnosis and treatment. The patient presents lying in bed resting. The patient was alert and oriented to time, partially to location, month, year, and situation. The patient has never seen a psychiatrist but has a history of difficulty with concentrating. Currently, the patient is having severe “sadness” concerning his health issues and is not wanting to die. The patient is also very anxious about his health issues. The patient complains of irritability and mood swings. The patient is not sleeping well in the hospital. Last night, the patient slept about 4 hours. The patient is eating fair. No auditory or visual hallucinations or paranoia. The patient denies any suicidal or homicidal ideation and concerns for safety. Per RN, the patient has not been expressing suicidal or homicidal ideation.

Past Psychiatric History: The patient has never been hospitalized in a psychiatric hospital and never had a suicide attempt.

Family Psychiatric History: His mother had mood issues and attempted to kill family so that they could all be together in heaven.

Past Medical and Surgical History: Paraplegic secondary to a gunshot wound in 19XX, neurogenic bladder status post suprapubic catheter, chronic wound, chronic osteomyelitis, chronic pain.

Drug and Alcohol History: The patient does not drink, smoke, or use illicit drugs.

Social History: The patient is divorced. He is on disability. He has 2 grown children, 1 son with whom he is estranged. Lives with his daughter and son-in-law.

ALLERGIES: Penicillin and gentamicin

Home Medications: Suboxone Diazepam 5 mg tid PRN spasms Ritalin 20 mg PO bid Ambien 5 mg PO q HS PRN sleep

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334 | Appendix A

MENTAL STATUS EXAMINATION: Orientation: Oriented to person, place, time, and situation. Behavior is anxious, cooperative, distractible. Speech is unremarkable. No circumstantial, tangential, or pressured speech. Mood is depressed, anxious, fearful, withdrawn, apathetic. Affect is congruent to mood. Thought process is appropriate, logical, intact, relevant. No flight of ideas. Association is appropriate, not circumstantial, loose, or tangential. Rate of thought is normal. Thought content is possibly delusional. No paranoia, no auditory or visual hallucinations. No ideas of influence or reference. No misinterpretations. No preoccupations with violence. Suicidal ideation: none; plan – none; risk – none. Homicidal ideation: none; plan – none, risk – none. Insight is subjectively intact. Judgment is intact, able to make sensible decisions, appropriate in social situations.

ASSESSMENT: AXIS I: Depression, not otherwise specified; anxiety, not otherwise specified; mood disorder, not otherwise spec- ified; attention deficit disorder, rule out delusional disorder.

AXIS II: Deferred.

AXIS III: Paraplegic secondary to gunshot wound. Neurogenic bladder, chronic decubitus ulcer with osteomyelitis, and chronic pain.

AXIS IV: Interpersonal.

AXIS V: 45-55.

PLAN: This patient presents with mood issues, anxiety, and possible delusional disorder. The patient denies suicidal and homicidal ideation. I recommended Zyprexa, but the patient is declining psychiatric medication at this time. Continue current psychiatric medications. Risks, benefits, and side effects discussed. The patient understands risks, benefits, and side effects of the medications. Supportive therapy provided. Once medically cleared, the patient is okay from psychiatric standpoint to be discharged. The patient was given follow-up information with outpatient psychiatry.

AnaMaria Ricardo, APRN

Jacob Kaplan, MD

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Appendix A | 335

Patient: M.B. The next set of documents is the prenatal record for patient M.B.

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336 | Appendix A

Patient: M.B. Obstetrical Record

Madison Palmer, MMS, PA-C

Initial Physical Exam Date Completed: 4/20/20XX Weight: 138 lb Height: 65 inches Blood Pressure: 118/70 Pre-Ob Weight: 138 lb BMI: 22.96 Pulse: 78

Appearance: NAD Thyroid: No nodules Breasts: Normal to inspection and palpation Heart: RRR, no m/r/g Extremities: No edema or varicosities Vulva: No masses or lesions Vagina: No abnormal discharge Cervix: Long, thick, closed Uterus: Mobile, nontender Adnexa: Nontender, no masses

Determination of Gestational Age Last Menstrual Period: 2/24/20XX Cycle Length: q28 and regular

Lungs: CTA bilaterally Abdomen: Soft, nontender, bowel sounds

normoactive

Back: No CVA tenderness Date of conception: Unknown Preliminary Estimated Date of Confinement:

12/01/20XX

U/S Estimate of EDC: 12/18/20XX U/S Estimate of Gestational Age: 7w4d Date Performed: 05/05/20XX Clinical EDC: 12/18/20XX

* The clinical EDC is the clinician’s best estimate of the due date and is the date used for clinical management.

Patient Information Name: M.B. Address: 1125 1st Avenue City/State/Zip: Minneapolis, MN 55401 Date of Birth: 01/13/19XX Baby’s Father: Age: 26 Name: J.B. Marital Status: Married Age: 28

Medical History Personal Medical History: None Medication Allergies: NKDA Surgeries: Tonsillectomy (19XX)

Family History Mother: Age 60, HTN controlled; hyperlipidemia Father: Age 61, Healthy Siblings: Sister: Age 29, Healthy Paternal Grandfather: Type 2 DM, deceased age 81 Maternal Grandmother: Lung CA, deceased age 71

Pregnancy History Gravida 2, Para 1-0-0-1, SAB 0, EAB 0, Stillborn 0, Neonatal Death 0, Other Loss 0, Premature 0

Date Weeks Duration of Labor Sex Wt Delivery Mode Neonatal Problems OB Problems 07/20/20XX 40 12 hr M 8 lb 0 oz NSVD None None

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Appendix A | 337

OB Visit Flow Sheet Age 26, G2 P1-0-0-1, Preliminary EDC 12/01/20XX, Clinical EDC 12/18/20XX as of 05/05/20XX, US

EDC 12/18/20XX

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

04/20/20XX Unknown N/A N/A N/A N/A -/- 138 118/70 2 weeks

Patient congratulated and welcomed. Pt is unsure of LMP, will confirm EDC with U/S next visit. Prenatal care, hospital facilities, and coverage arrangements discussed at length. Initial OB exam completed. Pap, gonorrhea/chlamydia screening and urine culture sent. Encouraged prenatal vitamin daily, Rx sent to patient’s pharmacy. New OB labs completed today. Pt given spontaneous abortion precautions.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

05/05/20XX 7w4d N/A N/A 160 N/A -/- 138 110/60 4 weeks

Pt denies vaginal bleeding or cramping. U/S today shows viable intrauterine pregnancy, 7w4d with EDC of 12/18/20XX, EDC adjusted to U/S dating. New OB labs WNL. Pt reports morning sickness, no emesis. Recommend patient avoid known triggers, eat small frequent meals throughout the day, continue good hydration, ginger products. If no improvement with conservative measures, will discuss medical management next visit. Discussed genetic screening options, patient and husband decline all testing.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

06/02/20XX 11w4d N/A N/A N/A N/A -/- 141 120/72 4 weeks

Pt doing well. She denies cramping, vaginal bleeding, or other complaints. Nausea completely resolved. Reviewed SAB precautions with patient, warning signs, when to call or go to ED.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

07/5/20XX 16w2d N/A N/A 165 N/A -/- 143 120/72 4 weeks

Pt presents for ROB visit, doing well. No concerns. Anatomy U/S scheduled for next visit.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

07/31/20XX 20w N/A Cephalic 150 + -/- 148 122/70 4 weeks

Anatomy U/S completed today, all anatomy seen and WNL. Pt reports dysuria and urinary frequency. UA negative in office. Urine and vaginal cultures collected and sent. Continue good nutrition, hydration, PNV daily. Given ED precautions.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

8/24/20XX 23w3d 24 N/A 145 + -/- 160 100/56 4 weeks

Pt denies vaginal bleeding, loss of fluid, or contractions. Active fetal movement. Cultures negative from last visit. Pt denies symptoms of UTI. Reviewed healthy diet in pregnancy, encouraged exercise 30 min daily. Preterm labor precautions given.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

9/25/20XX 28w 28 N/A 154 + -/- 167 120/72 2 weeks

28-week labs w/glucose tolerance test completed today. Pt feeling well, but c/o low back pain. Recommend increased rest, heating pad, pregnancy support belt, Tylenol PRN. Tdap and flu vaccine recommended. Pt agrees to both vaccinations. Encouraged Tdap for family/caregivers. Growth U/S scheduled in 2 weeks.

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338 | Appendix A

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

10/09/20XX 30w 31 Cephalic 158 + -/- 170 115/70 2 weeks

Growth U/S reviewed- Fetal growth WNL, cephalic presentation, EFW 1,538 g (3 lb 6 oz), overall growth 54th percentile. Third trimester labs reviewed and WNL. Pt denies reg cxt/LOF/VB. Active FM. PTL precautions given. Pt voices no other concerns. Pt given Rx for breast pump.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

10/23/20XX 32w 31 N/A 166 + -/- 175 110/66 2 weeks

Pt denies reg cxt/LOF/VB. She reports occasional Braxton Hicks cxts. Active FM, pt performing fetal kick counts daily. Discussed symptoms of pre-eclampsia, when to RTC or go to the hospital. Pt encouraged to register with hospital and schedule hospital tour.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

11/09/20XX 34w3d 33 Cephalic 145 + -/- 176 118/76 2 weeks

Pt presents for routine OB visit. She reports good FM. Pt voices no other concerns. Group B Strep culture next visit. Reviewed options of labor anesthesia and discussed birth plan with pt. PTL precautions given to pt.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

11/22/20XX 36w2d 36 Cephalic 129 + -/- 177 126/78 1 week

Patient reports fatigue, otherwise feeling well. Denies regular cxt/LOF/VB. She endorses good FM. GBS culture done today. She declines cervical exam today. Discussed cord blood banking, provided informational pamphlet.

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

11/29/20XX 37w2d 37 Cephalic 138 + -/- 178 118/72 1 week

Pt reports cxt last night, 10 minutes apart ×1 hour, eventually resolved with rest. Today, pt denies reg cxt/LOF/VB. GBS culture reviewed and negative. Reviewed labor & delivery precautions with pt. Pt would like to be checked for dilation. Bishop Score: 2 (2 cm/40/-3/post/medium).

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

12/07/20XX 38w3d 38 Cephalic 125 + -/- 178 129/82 1 week

Pt reports increased pelvic pressure and irregular BH cxt. No LOF or VB. Denies cxt/LOF/VB. Active FM. Discussed postpartum birth control options with pt. Labor warning signs reviewed with pt. Bishop Score: 5 (3 cm/50/-3/post/soft).

Visit Date Weeks Fundal Height Position FHT Fetal Activity Urine P/S Wt BP Return Visit

12/15/XX 39w4d 40 Cephalic 131 + -/- 179 127/87 1 week

Pt presents for ROB visit. Pt is experiencing continued irregular cxt. Good FM. Discussed post-dates surveillance and induction. Given L&D precautions. If undelivered, will complete Biophysical Profile next visit. Bishop Score: 7 (4 cm/60/-2/ post/soft).

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Appendix A | 339

Laboratory Studies Basic Prenatal Panel Date: 4/20/20XX HGB: 11.8 HCT: 36.0 Antibody Screen: Negative MCV: 90 Platelets: 394 RPR/VDRL: Nonreactive Urine Culture: No growth HBSAg: Negative HIV Testing: Negative Rubella Screen: Immune Chlamydia: Negative Gonorrhea: Negative Pap Smear: Negative cytology

Aneuploidy Screening Date: 05/05/20XX Declined

Late Pregnancy Panel Date: 9/25/20XX Glucose Screen: 80 HGB: 11.7 HCT: 37.1 MVC: 97 Platelets: 250 Antibody Screen: Negative RPR/VDRL: Nonreactive GBS: Negative

Optional Lab Studies CF Screen Other Carrier Screen Varicella Immunity Drug Screen Early Glucose

3-hr GTT F_ 1 hr_ 2 hr_ 3 hr

Assessment/Ongoing Problem List Date Code Description 4/20/20XX Z34.81 Multigravida in first trimester 4/20/20XX Z32.01 Encounter for pregnancy test, result positive 4/20/20XX Z11.3 Screening for STD (sexually transmitted disease) 4/20/20XX Z12.39 Screening Breast Examination 5/5/20XX O21.9 Nausea/vomiting in pregnancy 5/5/20XX V22.0 Preg, Norm 1st, Supervision of 5/5/20XX Z31.5 Encounter for genetic counseling and testing 6/2/20XX Z34.81 Multigravida in first trimester 7/5/20XX Z34.82 Multigravida in second trimester 7/31/20XX Z36.89 Encounter for fetal anatomic survey 7/31/20XX R30.0 Dysuria 8/24/20XX Z34.82 Multigravida in second trimester 9/25/20XX O26.893 Low Back Pain during pregnancy, third trimester 9/25/20XX V23 Need for diphtheria-tetanus-pertussis (Tdap) vaccine 9/25/20XX Z23 Flu vaccine need 10/9/20XX Z34.83 Multigravida in third trimester 10/23/20XX Z34.83 Multigravida in third trimester 11/9/20XX Z34.83 Multigravida in third trimester 11/22/20XX Z34.83 Multigravida in third trimester 11/29/20XX O47.9 Braxton Hicks contractions 12/7/20XX Z34.83 Multigravida in third trimester 12/15/20XX Z34.83 Multigravida in third trimester

Exposures Affecting Health Date Completed: 04/20/20XX 1. Do you use tobacco? No 2. Do you drink alcoholic beverages? No 3. Please list any medications taken since your last period, including over-the-counter medications: None 4. Please list any drug use in the past and dates last used: None 5. Do you have any reason to believe you may have been exposed to AIDS? No 6. Do you work with chemicals or radiation? No

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340 | Appendix A

7. Do you have cats? No 8. Have you had an influenza (flu) vaccine? No

Gynecologic Health History Date Completed: 04/20/20XX 1. Last menstrual cycle: 2/24/20XX 2. Last Pap smear: 03/03/20XX

a. Have you ever had an abnormal Pap smear? No 3. Have you ever had gonorrhea or chlamydia? No 4. Do you or your partner have a history of genital herpes? No 5. Did you receive the HPV vaccine? Yes 6. Do you have a history of kidney or bladder infections? No 7. Do you have a history of infertility? No 8. Do you have any religious or other objections to any form of medical treatment you would like to make us

aware of? No Genetic History Date Completed: 04/20/20XX 1. Have either you or the baby’s father had a child with a birth defect? No 2. Did either you or the baby’s father have a birth defect yourselves? No 3. Please describe any abnormalities that have occurred in your family or the baby’s father’s family. None 4. Do either you or the baby’s father have a history of pregnancy losses, miscarriages, stillborn? No 5. Are you or the baby’s father of Jewish ancestry? No

a. If yes, have you had Tay-Sachs screening? N/A 6. Are you or the baby’s father African American? No

a. If yes, have you had sickle cell screening? N/A

Topics for Discussion by Trimester I. First Trimester Date Completed: 06/02/20XX

• Anticipated course of prenatal care • Reviewed potential risk factors identified by prenatal history • How to reach physician after hours • Discuss genetic screening options • Discussion of nutrition and weight gain, diabetic teaching (if applicable) • Discuss psychosocial issues • Discuss indications for U/S • Warning signs of spontaneous/threatened miscarriage • Toxoplasmosis exposure and prevention discussed

II. Second Trimester Date Completed: 08/24/20XX • Discuss first and third trimester lab values • Discuss influenza vaccine • Select pediatrician • Review warning signs and symptoms of preterm labor in second trimester • Discussed and provided pamphlet of cord blood banking

III. Third Trimester Date Completed: 12/15/20XX • Discuss hospital facilities and physician coverage • Review signs and symptoms of pre-eclampsia and other emergencies • Discuss labor anesthesia and birth plan • Discuss signs of labor • Instruct patient to call immediately or go to ED if signs of labor, especially prior to 36 weeks • Discussion regarding VBAC, including risks • Provided contact numbers/instructions for after-hours emergency care • Post-dates counseling for weeks 40–41 • Discuss possibility of C-section and indications • Fetal well-being surveillance (i.e., fetal kick counts) • Postpartum depression • Instructed on use of infant car seats and seat belts

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Appendix A | 341

Patient: R.B. The next set of documents is the pediatric records for R.B., the child delivered by M.B. There are records of both well-child visits as well as visits for acute illnesses.

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342 | Appendix A

HPI: 3-day-old female presents with parents for newborn well check, first visit since hospital discharge. Birth history uncomplicated as below. Pt breastfeeding, latching well. No formula needed. Voiding and stooling well. No parental concerns.

Birth History: Full term-40w2d, spontaneous vaginal delivery with no vacuum or forceps, birth weight 7 lb 2 oz, Apgars 7 and 9. Passed newborn hearing screen. 1st Hep B administered in hospital, vitamin K and erythromycin eye ointment received. First newborn screen sent, no jaundice, bilirubin WNL. No maternal complications.

Family/Social History: Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: ˛ Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)

Nutritional Screening: ˛ Breastfeeding Frequency/Duration: Bilateral, 10 min each side every 2–3 hours

Developmental Surveillance: ˛ Rooting Reflex ˛ Startle ˛ Suck & Swallow

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ̨ Safe Sleep ̨ Shaken Baby Prevention ̨ Safe Bathing/Water Temperature ˛ Passive Smoke ˛ Safety at Home/ChildProofing ˛ Sun Safety ˛ Pacifier Use ˛ Bottle Propping ˛ Infant Bonding ˛ Support Systems/Resources ˛ Infant Crying/Appropriate Interventions

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child

Patient: R.B. Newborn Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 3 days

Accompanied By: Mother and Father

Admitted to NICU: No

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference Temp Pulse Respirations

7 lb 2 oz 19.5 in. 13.5 in. 98.6 152 48

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Appendix A | 343

˛ Appropriate Bonding/Responsive to Needs ̨ Infant Hands to Mouth/Self-Calming ̨ Baby Blues/ Postpartum Depression

Comprehensive Physical Exam:

Gen: Well appearing, sleeping initially, alert during exam

Skin: Normal turgor without rash or lesions, no jaundice

HEENT: Normocephalic, anterior fontanelle open/flat. PERRL, +red reflex bilaterally, no icterus, no drainage. Normal external ears; TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple with no mass or deformity.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4, umbilical stump dried/intact, no drainage

GU: Normal female external genitalia

MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight, no hair tuft or sacral dimple

Neuro: Normal suck, grasp, and Moro reflexes

Assessment:

Health examination for newborn under 8 days old – Z00.110

Pediatric well check/infant under 1 year – 99381

Plan:

Pt already back to birth weight and exam WNL, follow-up at 1 month well check, sooner with questions or concerns

Start vitamin D 400 units daily while exclusively breastfeeding

Vaccines UTD

Obtain 2nd newborn screen at about 1 week old

Discussed cord care

Fever greater than 100.4 under 60 days old – go to ED

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344 | Appendix A

HPI: 1-month-old female presents with parents for well check. Pt breastfeeding, continues to latch well. No formula needed. Started vitamin D 400 units daily. Reports cord fell off at 1 week old, healing well. Starting tummy time. Voiding and stooling well. No parental concerns.

Birth History: Full term-40w2d, spontaneous vaginal delivery with no vacuum or forceps, birth weight 7 lb 2 oz, Apgars 7 and 9, passed newborn hearing screen, 1st Hep B administered in hospital, vitamin K and erythromycin eye ointment received. First newborn screen sent, no jaundice, bilirubin WNL. No maternal complications.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: ˛ Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)

Nutritional Screening: ˛ Breastfeeding Frequency/Duration: Bilateral, 10 min each side every 2–3 hours

Developmental Surveillance: ˛ Responds to Sounds ˛ Responds to Parent’s Voice ˛ Follows with Eyes to Midline ˛ Awake for 1-Hour Stretches ˛ Beginning Tummy Time

Anticipatory Guidance Provided: ˛ Emergency/911 ˛ Gun Safety ˛ Drowning Prevention ˛ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ˛ Safe Sleep ˛ Shaken Baby Prevention ˛ Safe Bathing/ Water Temperature ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Bottle Propping ˛ Infant Bonding ˛ Support Systems/Resources ˛ Infant Crying/Appropriate Interventions

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child

˛ Appropriate Bonding/Responsive to Needs ̨ Infant Hands to Mouth/Self-Calming ̨ Postpartum Depression

One-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 1 month

Accompanied By: Mother and Father

Current Medications: Vitamin D 400 units daily

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

9 lb 3 oz 21.25 in. 14.5 in. 98.4 148 46

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Appendix A | 345

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert

Skin: Normal turgor without rash or lesions, no jaundice

HEENT: Normocephalic, anterior fontanelle open/flat. PERRL, +red reflex bilaterally, no icterus, no drainage. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple with no mass or deformity.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4, umbilicus dry/healing, no drainage

GU: Normal female external genitalia

MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight

Neuro: Normal suck, grasp, and Moro reflexes

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/infant under 1 year – 99381

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 2-month well check, sooner with questions or concerns

Continue vitamin D 400 units daily while exclusively breastfeeding

Vaccines UTD – to start routine vaccines at 2-month well check

2nd newborn screen obtained, pending results

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346 | Appendix A

HPI: 2-month-old female presents with mother for well check. Pt breastfeeding, going well. No formula needed. Pt starting to sleep longer stretches at night. Voiding and stooling well. +tummy time—starting to get some head control. + Smiling. Pt healthy, ready to start vaccines today. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: ˛ Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)

Nutritional Screening: ˛ Breastfeeding Frequency/Duration: Bilateral, 10 min each side every 2.5–3 hours

Developmental Surveillance: ˛ Some Head Control ˛ Tummy Time/Lifts Head, Neck with Forearm Support ˛ Social Smile ˛ Coos ˛ Beginning Imitation of Movement and Facial Expressions ˛ Makes Eye Contact ˛ Fixes/Follows with Eyes to Midline ˛ Startles at Loud Noises

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ̨ Safe Sleep ̨ Shaken Baby Prevention ̨ Safe Bathing/Water Temperature ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Pacifier Use ˛ Bottle Propping ˛ Infant Bonding ˛ Support Systems/Resources ˛ Infant Crying/Appropriate Interventions ˛ Parent Reads to Child

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child

Two-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 2 months

Accompanied By: Mother

Current Medications: Vitamin D 400 units daily

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

11 lb 6 oz 22.75 in. 15.25 in. 98.5 142 42

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Appendix A | 347

˛ Appropriate Bonding/Responsive to Needs ˛ Infant Hands to Mouth/Self-Calming ˛ Enjoys Interacting with Others ˛ Postpartum Depression

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert

Skin: Normal turgor without rash or lesions, no jaundice

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight

Neuro: Normal suck, grasp, and Moro reflexes, alert

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/infant under 1 year – 99381

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 4-month well check, sooner with questions or concerns

Continue vitamin D 400 units daily while exclusively breastfeeding

Vaccines given today – Hep B, Rotavirus, DTaP, Hib, PCV 13, and IPV – Vaccine education provided including possible side effects and VIS given

Both newborn screens received – normal

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348 | Appendix A

HPI: 4-month-old female presents with father for well check. Pt continues to breastfeed exclusively, which is going well. No formula needed. Voiding and stooling well. Starting to babble, laugh, and roll from front to back. +Tummy time. Sleeping 5–6-hour stretches at night. Parents have not started introducing solids yet. Pt tolerated first set of vaccines well with minimal fussiness and no fever. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: ˛ Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)

Nutritional Screening: ˛ Breastfeeding Frequency/Duration: Bilateral, 5–10 min each side every 2.5–3 hours

Developmental Surveillance: ˛ Babbles and Coos ˛ Laughs ˛ Begins to Roll Front to Back ˛ Pushes Up with Arms ˛ Controls Head Well ˛ Reaches for Objects ˛ Interest in Mirror Images ˛ Pushes Down with Legs When Feet on Surface ˛ Appropriate Eye Contact ˛ Tummy Time

Anticipatory Guidance Provided: ˛ Emergency/911 ˛ Gun Safety ˛ Drowning Prevention ˛ Choking Prevention ̨ Car/Car Seat Safety (Rear-Facing) ̨ Safe Sleep ̨ Shaken Baby Prevention ̨ Safe Bathing/Water Temperature ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Bottle Propping ˛ Support Systems/Resources ̨ Infant Crying/Appropriate Interventions ̨ Discuss Child Temperament ̨ Establish Daily Routines/Infant Regulation ˛ Establish Nighttime Sleep Routine/Sleep Through Night (Greater Than 5 hours) ˛ Parent Reads to Child

Four-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 4 months

Accompanied By: Father

Current Medications: Vitamin D 400 units daily

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

14 lb 3 oz 24.5 in. 16.25 in. 98.7 128 36

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Appendix A | 349

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Baby ˛ Appropriate Bonding/Responsive to Needs ˛ Infant Hands to Mouth/Self-Calming ˛ Smiles When Hears Parents’ Voices ˛ Easily Distracted/Excited by Discovery of Outside World ˛ Postpartum Depression

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert, smiling

Skin: Normal turgor without rash or lesions

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight, pushes up when prone

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/infant under 1 year – 99381

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 6-month well check, sooner with questions or concerns

Continue vitamin D 400 units daily while exclusively breastfeeding

Introduce solids anytime between now and 6 months. Start with infant iron-fortified oatmeal cereal mixed with breastmilk or formula and a spoonful of pureed fruit. Advance as able to vegetable and fruit purees.

Discussed symptoms of teething – first tooth erupts at around 6 months of age on average

Vaccines given today – Rotavirus, DTaP, Hib, PCV 13, and IPV – Vaccine education provided including possible side effects and VIS given

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350 | Appendix A

HPI: 6-month-old female presents with parents for well check. Pt continues to breastfeed and parents are also giving oatmeal cereal with fruit once a day and pureed vegetables once a day. No formula needed. No juice. Pt now rolling both ways and sitting up with support. Voiding and stooling well. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: ˛ Daily Gum Cleaning with Washcloth or Infant Toothbrush (Parent Education Completed)

Nutritional Screening: ˛ Breastfeeding Frequency/Duration: Bilateral, 5–10 min each side every 3–4 hours ˛ Oatmeal cereal with fruit and vegetable purees

Developmental Surveillance: ˛ Using a String of Vowels ˛ Rolls Over ˛ Transfers Small Objects ˛ Vocal Imitation ˛ Sits with Support ˛ Explores with Hands and Mouth ˛ Peek-a-Boo/Patty Cake

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ˛ Safe Sleep ˛ Shaken Baby Prevention ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ̨ Sun Safety ̨ Refrain from Jump Seat/Walker ̨ Sleep/Wake Cycle ̨ Introduce Cup ˛ Begin Using High Chair ˛ Wary of Strangers ˛ Introduce Board Books ˛ Parent Reads to Child

Six-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 6 months

Accompanied By: Mother and Father

Current Medications: Vitamin D 400 units daily

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

16 lb 2 oz 26.25 in. 16.75 in. 98.4 120 32

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Appendix A | 351

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Baby

˛ Appropriate Bonding/Responsive to Needs ̨ Recognized Familiar People ̨ Distinguishes Emotions by Tone of Voice ˛ Self-Calming ˛ Enjoys Social Play ˛ Postpartum Depression

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert

Skin: Normal turgor without rash or lesions

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, spine straight, sits up with support

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/infant under 1 year – 99381

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 9-month well check, sooner with questions or concerns

Continue vitamin D 400 units daily while breastfeeding

Continue oatmeal cereal/vegetables and advance solids as able. Start offering pureed meat. Introduce sippy cup with water.

Vaccines given today – Hep B, Rotavirus, DTaP, Hib, PCV 13, and IPV – Vaccine education provided including possible side effects and VIS given

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352 | Appendix A

HPI: 9-month-old female presents with mother for well check. Pt is no longer breastfeeding since about a month ago, now on Similac Advance 6–8 oz 3–4×/day. Discontinued vit D supplement. Pt eats oatmeal cereal with fruit for breakfast and meat/fruit/vegetables for lunch and dinner. Starting to offer table foods. Takes water from sippy cup. No juice. Crawling, starting to say mama/dada nonspecific, sleeping 8–10-hour stretches at night. Voiding and stooling well. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Developmental Screening Tool Completed: ˛ PEDS – Score 0/Path E

Verbal Lead Risk Assessment: Child at Risk: ®Yes ˛No Lives in High-Risk Zip Code: ˛Yes ®No

Oral Health: White Spots on Teeth: ®Yes ˛No ˛Parent Cleaning Baby’s Gums with Infant Toothbrush ˛ Fluoride Varnish by PCP

Nutritional Screening: ̨ Formula – Similac Advance, 6–8 oz 3– 4×/day ̨ Oatmeal cereal, meat, fruit, vegetables; starting table foods ˛ Drinks from Cup

Developmental Surveillance: ˛ Sits Independently ˛ Pulls to Stand/Cruising ˛ Plays Peek-a-Boo ˛ Uses Words “Mama/Dada” ˛ Waves Bye-Bye ˛ Wary of Strangers ˛ Immature Pincer ˛ Repeats Sounds/Gestures for Attention ˛ Explores Environment

Nine-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 9 months

Accompanied By: Mother

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

18 lb 10 oz 27.5 in. 17.5 in. 97.9 118 30

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Appendix A | 353

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention/ Soft Texture Finger Foods ˛ Car/Car Seat Safety (Rear-Facing) ˛ Safe Sleep ˛ Shaken Baby Prevention ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Sleep/Wake Cycle ˛ TV Screen Time ˛ Exploration/Learning ˛ Redirection/Positive Parenting ˛ Language/Read to Child/Introduce Board Books ˛ Follow Child’s Lead in Play ˛ Parent Communicates to Child “What Things Are” (Ball, Cat, etc.) Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child

˛ Appropriate Bonding/Responsive to Needs ˛ Self-Calming ˛ Growing Independence ˛ Shows Preference for Certain People/Toys ˛ Cries When Primary Caregiver Leaves ˛ Postpartum Depression

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert, smiling, babbling

Skin: Normal turgor without rash or lesions

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone spine straight, sits independently, crawling

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/infant under 1 year – 99381

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 12-month well check, sooner with questions or concerns

Continue with current feeding regimen, advance soft/small bites table foods as able

PEDS tool negative for developmental concerns

Brush teeth with grain of rice-sized amount of fluoride toothpaste in the morning and after all food/formula before bed. First dental visit should be around 12 months old.

UTD on vaccines, none needed today. Screening hgb/hct and lead ordered.

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354 | Appendix A

CC: Fever, Runny Nose, Cough

HPI: 10-month-old female presents with her mother for a 6-day history of clear/yellow rhinorrhea progressing to a wet cough. Fever started last night, T max 102.5, treated with Motrin initially and then given a dose of Tylenol 1 hour ago for a fever of 101.6. Current temp 99.2. Tugging on right ear, no drainage. Decreased appetite but drinking well. Fussy and waking up once or twice at night. Voiding well. No V/D.

ROS:

+fever, +runny nose, +cough, +decreased appetite, +fussy, +ear pain

-vomiting, -diarrhea, -wheezing, -rash, -ear drainage, -eye redness or drainage

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Physical Exam:

Gen: Well appearing/well hydrated, sleeping initially in mother’s arms. Alert upon awakening, fussy during exam.

Skin: Normal turgor without rash or lesions

Pediatric Sick Visit

Name: R.B.

DOB: 12/20/20XX

Age: 10 months

Accompanied By: Mother

Current Medications: Ibuprofen/Tylenol

Allergies: NKDA

Vital Signs:

Weight Length Temp Pulse Respirations

19 lb 2 oz 28.25 in. 99.2 132 34

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Appendix A | 355

HEENT: Anterior fontanelle open/flat. PERRL, no conjunctivitis, no drainage. Normal external ears, left TM normal, right TM erythematous/bulging. +clear nasal discharge. Normal size tonsils, no erythema or exudate, neck supple, no lymphadenopathy.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB, +occasional wet cough

CV: Regular rate and rhythm, no murmur, cap refill less than 3 sec

Abd: Soft, nondistended, bowel sounds positive ×4

MSK: Normal muscle tone, no joint swelling or stiffness

Neuro: Alert

Assessment:

Right otitis media – H66.91

URI – J06.9

Plan:

Amoxicillin 400 mg/5 mL – 4.5 mL PO bid ×10 days

Return for ear recheck in 10 days

Continue treating fever with Tylenol every 4 hr PRN and Motrin every 6 hr PRN

Supportive care for URI – push fluids, nasal saline/suction, sleep upright to help with drainage, humidifier while sleeping

Return to clinic if condition persists or worsens over the next few days, to ED if difficulty breathing

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356 | Appendix A

HPI: 12-month-old female presents with father for well check. Pt continues taking Similac Advance, currently 8 oz 3×/day. No cow’s milk yet. Pt doing well with table foods, feeds self and improving pincer grasp. Pt eats a good variety of fruits, vegetables, meat, and starting to eat some cheese and yogurt. No juice. Just started taking a few steps. Voiding and stooling well. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing (Twice by Parent) First Dental Appointment ® Completed ˛ Scheduled Dental Home: Dr. Sharman

Nutritional Screening: ˛ Formula – Similac Advance, 8 oz 3×/day ˛ Table foods—fruit, vegetables, and meat, starting cheese/yogurt

Developmental Surveillance: ˛ First Steps ˛ “Mama/Dada” Specific ˛ Uses Single Words ˛ Scribbles ˛ Precise Pincer Grasp ˛ Follows Simple One-Step Requests ˛ Looks for Hidden Objects ˛ Extends Arm/Leg for Dressing ˛ Points to Objects ˛ Plays: Hides Object/Pushes Ball Back and Forth

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety

Twelve-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 12 months

Accompanied By: Father

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

20 lb 3 oz 29.5 in. 18.25 in. 98.0 112 28

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Appendix A | 357

˛ Discipline/Praise ˛ Following Child’s Lead in Play ˛ Ignore Tantrums/Give Attention to Positive Behaviors

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child ˛ Self-Calming ˛ Prefers Primary Caregiver over All Others ˛ Shy/Anxious with Strangers ˛ Tantrums

Comprehensive Physical Exam:

Gen: Well appearing, awake and alert, smiling/playful

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic, anterior fontanelle closed. PERRL, +red reflex bilaterally, no icterus, no drainage. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent, neck supple with no mass or deformity. Three bottom teeth and four top teeth.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, femoral pulses 2+

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, spine straight, starting to walk

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/early childhood (1–4 years) – 99382

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 15-month well check, sooner with questions or concerns

Continue with current feeding regimen, continue to advance table foods as able and offer a variety of healthy foods. Transition from formula to whole or 2% milk in sippy cup. Discontinue bottle and pacifier.

Vaccines given today – MMR, Varicella, and Hep A – Vaccine education provided including possible side effects and VIS given

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358 | Appendix A

Fifteen-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 15 months

Accompanied By: Mother

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

21 lb 5 oz 30.5 in. 18.5 in. 97.9 115 26

HPI: 15-month-old female presents with mother for well check. Pt doing well with table foods, eats a variety of fruits, vegetables, meats, whole grains, cheese, and yogurt. Drinks 16–24 oz of whole milk per day from sippy cup, no juice. No longer using bottle or pacifier. Sleeps 10–11-hour stretches most nights but occasionally wakes up from teething pain. Voiding and stooling well. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing (Twice by Parent) ˛ Fluoride Varnish by PCP First Dental Appointment ˛ Completed ˛ Scheduled Dental Home: Dr. Sharman

Nutritional Screening: ˛ Feeds Self ˛ Whole Milk ˛ Nutritionally Balanced Diet

Developmental Surveillance: ˛ Says 3–6 words ˛ Says No ˛ Wide Range of Emotions ˛ Repeats Words from Conversation ˛ Uses Utensils ˛ Understands Simple Commands ˛ Climbs Stairs ˛ Walking ˛ Puts Objects In/Out of Container

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ̨ Safety at Home/Child-Proofing ̨ Sun Safety ̨ Helmet Use ̨ Growing Independence ˛ Defiant Behavior/Offer Child Choices ˛ Gentle Limit Setting/Redirection/Safety ˛ Reading/Parent Asks Child “What’s that?” ˛ Follow Child’s Lead in Play ˛ Offer Opportunity to Scribble/ Explore

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child ˛ Appropriate Bonding/ Responsive to Needs ˛ Self-Calming ˛ Frustration/Hitting/Biting/Impulse Control

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Appendix A | 359

˛ Communication/Language ˛ Social Interaction/Eye Contact/Comfort Others ˛ Begins to Have Definite Preferences

Comprehensive Physical Exam:

Gen: Well appearing, alert, interactive

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic, anterior fontanelle closed. PERRL, +red reflex bilaterally, no icterus, no drainage. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple with no mass or deformity. Four bottom teeth and four top teeth with no obvious caries.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, spine straight, walking/steady

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/early childhood (1–4 years) – 99382

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 18-month well check, sooner with questions or concerns

Continue with current feeding regimen, continue giving whole milk and a wide variety of healthy food choices

Vaccines given today – Hib & PCV13 – Vaccine education provided including possible side effects. VIS given.

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360 | Appendix A

Eighteen-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 18 months

Accompanied By: Mother

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

22 lb 14 oz 31.5 in. 18.75 in. 97.8 108 26

HPI: 18-month-old female presents with mother for well check. Pt continues to do well with table foods, eats a variety of fruits, vegetables, meats, whole grains, cheese, and yogurt. Drinks 16–24 oz of whole milk per day from cup, no juice. Voiding and stooling well. Development normal per parents, MCHAT and PEDS WNL. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Developmental Screening Tool Completed: ˛ MCHAT – WNL ˛ PEDS – Score 0/Path E

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing (Twice by Parent) ˛ Dental Visits Every 6 Months Dental Home: Dr. Sharman

Nutritional Screening: ˛ Feeds Self ˛ Whole Milk ˛ Nutritionally Balanced Diet

Developmental Surveillance: ˛ Uses a Cup ˛ Walks ˛ Says 10–20 Words ˛ Says “No” ˛ Name One Picture/2 Colors ˛ Follows Simple Rules/Bring Me the Book ˛ Knows Animal Sounds

Anticipatory Guidance Provided: ˛ Emergency/911 ˛ Gun Safety ˛ Drowning Prevention ˛ Choking Prevention ˛ Car/Car Seat Safety (Rear-Facing) ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Helmet Use ˛ Never Leave Toddler Alone ˛ Sibling Interaction ˛ Discipline/Limits ˛ Growing Independence ˛ Encourage Expression of Wide Range of Emotions ˛ Read to Child

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child ˛ Appropriate Bonding/ Responsive to Needs ˛ Self-Calming ˛ Frustration/Hitting/Biting/Impulse Control ˛ Communication/Language ̨ Demonstrates Increasing Independence ̨ Defiant Behavior/Offer Child Choices

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Appendix A | 361

Comprehensive Physical Exam:

Gen: Well appearing, alert, active

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic. PERRL, +red reflex bilaterally, no icterus, no drainage. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple with no mass or deformity. All teeth in place except 2-year molars; no obvious caries.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, spine straight

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/early childhood (1–4 years) – 99382

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 24-month well check, sooner with questions or concerns

Continue with current feeding regimen, continue giving whole milk and offering a wide variety of healthy food choices

Development WNL, return for questions or concerns regarding speech or development

Vaccines given today – DTaP & Hep A – Vaccine education provided including possible side effects. VIS given.

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362 | Appendix A

Twenty-Four-Month Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 24 months

Accompanied By: Father

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Length Head Circumference

Temp Pulse Respirations

26 lb 4 oz 33.75 in. 18.75 in. 98.8 99 24

HPI: 24-month-old female presents with father for well check. Pt continues to eat a variety of fruits, vegetables, meats, whole grains, cheese, and yogurt. Drinks 16–24 oz of whole milk per day from a cup, no juice. Voiding and stooling well. Shows some interest in potty training but not consistent. Pt is active/playful. Speech development WNL greater than 50 words. No developmental concerns per parents, MCHAT WNL. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Developmental Screening Tool Completed: ˛ MCHAT – WNL

Verbal Lead Risk Assessment: Child at Risk ® Yes ˛No Lives in High-Risk Zip Code ˛ Yes ® No

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing (Twice by Parent) ˛ Dental Visits Every 6 Months Dental Home: Dr. Sharman

Nutritional Screening: ˛ Feeds Self ˛ Whole Milk ˛ Nutritionally Balanced Diet

Developmental Surveillance: ˛ Kicks a Ball ˛ Stacks 5–6 Blocks ˛ 50-Word Vocabulary ˛ Walks Upstairs/ Runs Well ˛ Puts Two Words Together ˛ Jumps Up ˛ Follows Two-Step Commands

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Forward Facing) ˛ Safety at Home/Child-Proofing ˛ Sun Safety ˛ Trike/Bike Safety (Helmet Use) ̨ Establish Daily Routine ̨ Discipline/Redirection/Praise ̨ Provide Opportunities for Success/ Choice ˛ Praise for Effort/Success ˛ Encourage/Support Wide Range of Emotions ˛ Read to Child

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Appendix A | 363

Social-Emotional Health: ˛ Family Adjustment/Parent Responds Positively to Child ˛ Appropriate Bonding/ Responsive to Needs ˛ Self-Calming ˛ Frustration/Hitting/Biting/Impulse Control ˛ Communication/Language ̨ Sense of Humor ̨ Demonstrates Increasing Independence ̨ Plays Alongside Peers

Comprehensive Physical Exam:

Gen: Well appearing, alert, interactive

Skin: Normal turgor without rash or lesions

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia

MSK: Normal muscle tone, spine straight

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/early childhood (1–4 years) – 99382

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 3-year well check, sooner with questions or concerns

Continue with current feeding regimen, continue with whole or 2% milk and offer a wide variety of healthy food choices

Development WNL, return for questions or concerns regarding speech or development

UTD on vaccines – none needed today; sent to lab for blood lead level

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364 | Appendix A

Five-Year Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 5 years

Accompanied By: Mother

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Height BMI Blood Pressure

Temp Pulse Respirations

40.5 lb 42.25 in. 16.1 98/52 98.4 90 20

Vision and Hearing Screen WNL

HPI: 5-year-old female presents with mother for well check. Pt will be starting kindergarten and needs to complete vaccines for school. Pt is almost finished with her second year of preschool and has done very well. Pt eats a variety of fruits, vegetables, meats, some fish, whole grains, cheese, and yogurt. Drinks 16–24 oz of 2% milk per day, no juice. Pt is active for about 1 hour per day most days of the week. Voiding and stooling well. No parental concerns.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Twice Daily Brushing/Flossing (With Parent Assistance) ˛ Dental Visits Every 6 Months Dental Home: Dr. Sharman

Nutritional Screening: ˛ Nutritionally Balanced Diet/5 Servings Fruits & Veggies ˛ Activity/Family Exercise (1 hr/day)

Developmental Surveillance: ̨ Uses Imaginary Characters ̨ Matches Colors and Shapes/Prints Some Numbers and Letters ̨ Counts to 10 ̨ Follows Simple Directions ̨ Listens and Attends ̨ Can Button and Zip Clothing Independently ˛ Goes to Bathroom Independently ˛ Holds Pencil/Cuts with Scissors ˛ Cooperates More in Group Setting ˛ Good Articulation/Language Skills ˛ Hops/Skips

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Car Seat Safety (Booster Seat) ˛ Safety at Home ˛ Sun Safety ˛ Sports/Helmet Use ˛ Bullying ˛ Good and Bad Touches ̨ TV Screen Time ̨ Begins to Agree with Rules ̨ Dictates Story to Adults ̨ Listens to Authority Figure & Follows Instructions ˛ School Readiness ˛ Communication with Teachers

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Appendix A | 365

Social-Emotional Health: ̨ Family Adjustment/Parent Responds Positively to Child ̨ Self-Calming ̨ Wants to Please & Be with Friends ˛ Shows Empathy for Others ˛ Positive About Self & Abilities ˛ Tells Stories of Convenience (Lying)

Comprehensive Physical Exam:

Gen: Well appearing, alert, interactive

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic. PERRL, no drainage. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple with no mass or deformity. Mucous membranes moist. Good dentition with no obvious caries.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia, Tanner stage I/I

MSK: Normal muscle tone and strength, spine straight, full ROM

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/late childhood (5–11 years) – 99383

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 6-year well check, sooner with questions or concerns

Continue to make healthy food choices and stay active. The goal is 5 servings of fruits and vegetables per day. Maintain 3 servings of calcium foods per day (milk, cheese, yogurt).

Passed vision and hearing exam

Vaccines given today – DTaP, MMR, Varicella, & IPV – Vaccine education provided including possible side effects. VIS given.

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366 | Appendix A

Pediatric Sick Visit

Name: R.B.

DOB: 12/20/20XX

Age: 8 years

Accompanied By: Mother

Current Medications: Ibuprofen

Allergies: NKDA

Vital Signs:

Weight Length Temp Pulse Respirations Blood Pressure

54 lb 51 in. 100.7 118 20 112/72

CC: Fever, Sore throat

HPI: 8-year-old female presents with mother for a 2-day history of fever and sore throat. T-max 101.4, treating with ibuprofen, last dose 8 hours ago. Pt reports sore throat rated 5/10 and painful swallowing. Decreased appetite but drinking well. Pt has also had some intermittent abd pain described as generalized, dull/achy and nausea. No V/D. No rash.

ROS:

+fever, +sore throat, +abd pain, +nausea, +decreased appetite, +fatigue

-vomiting, -diarrhea, -rash, -ear pain/drainage, -eye redness or drainage, -nasal congestion/rhinorrhea, -cough, -body aches, -dysuria

Family/Social History: No sick family members. +sick exposure-strep has been going around at school.

Physical Exam:

Gen: Lying on exam table, appears uncomfortable but not toxic

Skin: Normal turgor without rash or lesions

HEENT: PERRL, no conjunctivitis, no drainage, normal external ears, TMs normal bilaterally, no nasal congestion or rhinorrhea, +moderate pharyngeal and tonsillar erythema, 3+ tonsillar enlargement with exudate, neck supple, +moderate cervical lymphadenopathy

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: +Mild tachycardia, no murmur, 2+ peripheral pulses and cap refill less than 3 sec

Abd: Soft, nondistended, nontender, no rebound tenderness, no organomegaly, normoactive bowel sounds

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Appendix A | 367

MSK: Normal muscle tone, no joint swelling or stiffness

Neuro: Alert, cranial nerves intact

Rapid Strep Positive

Assessment: Streptococcal pharyngitis – J02.0

Plan:

Amoxicillin 400 mg/5 mL – 7.5 mL PO bid ×10 days

Continue treating fever/pain with ibuprofen every 6 hr PRN; can also give Tylenol every 4 hr PRN

Salt water gargles/throat lozenges

Return to clinic if condition persists or worsens over the next few days or if fever persists greater than 48 hours

May return to school after 24 hours on antibiotics AND fever free

Change toothbrush in 1 week

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368 | Appendix A

Eleven-Year Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 11 years

Accompanied By: Father

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Height BMI Blood Pressure

Temp Pulse Respirations

85 lb 56.5 in. 18.7 108/70 98.6 84 18

Vision and Hearing Screen WNL – Corrected ® Yes ˛ No

HPI: 11-year-old female presents with dad for well check. Pt is in 6th grade and doing very well in school. She plans to play on the school volleyball team and needs clearance for sports participation. Pt eats a variety of fruits, vegetables, meats, some fish, whole grains, cheese, and yogurt. Drinks 16–24 oz of 2% milk per day, no juice. Pt is active for at least 2 hours per day most days of the week. Has not started menses yet. Pt/parent denies any history of syncope, chest pain with exercise, broken bones, asthma/wheezing, or seizures. All answers on sports physical questionnaire benign.

Family/Social History:

No sudden, unexplained death or heart problems in the family before age 50

Parental Concerns: None

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing 2× Daily/Flossing ˛ Dental Visits Every 6 Months Dental Home: Dr. Sharman

Nutritional Screening: ̨ Nutritionally Balanced Diet ̨ 5 Servings Fruits & Veggies ̨ Activity/Family Exercise (1 hr/day)

Developmental Surveillance: ˛ School Attendance ˛ Reading at Grade Level ˛ Discuss Body Changes ˛ Dating ˛ Sexuality/Orientation ˛ Performing Well in School

Anticipatory Guidance Provided: ̨ Emergency/911 ̨ Gun Safety ̨ Drowning Prevention ̨ Choking Prevention ˛ Car/Seat Belt Safety ˛ Safety at Home ˛ Sports/Injury Prevention ˛ Bullying/Violence Prevention ˛ Sun Safety ̨ Safety Rules with Adults ̨ Sex Education/STI ̨ Monitor TV/Computer Time ̨ Peer Refusal Skills ˛ Self-Control ˛ Depression/Anxiety ˛ Tobacco/Alcohol/Drugs/Rx Drugs/Inhalants ˛ Risks of Tattoos/ Piercing ˛ After-School Activities/Supervision ˛ Education Goals/Activities

Social-Emotional Health: ˛ Comfortable Body Image ˛ Feels Good About Self ˛ Is Child Happy? ˛ Social Interaction

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Appendix A | 369

Comprehensive Physical Exam:

Gen: Well appearing, alert

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic. PERRL. Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple without mass or deformity, no cervical lymphadenopathy. Mucous membranes moist, good dentition with no obvious caries.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur, 2+ peripheral pulses, cap refill less than 3 sec

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia, Tanner stage II/II

MSK: Normal muscle tone, 5/5 equal strength bilaterally on upper and lower extremities, spine straight— no scoliosis, full ROM throughout

Neuro: Alert, cranial nerves intact, normal DTRs

Assessment:

Routine child health exam without abnormal findings – Z00.129

Encounter for examination for participation in sport – Z02.5

Pediatric well check/late childhood (5–11 years) – 99383

Plan:

Excellent weight gain/growth/VS and exam WNL, follow-up at 12-year well check, sooner with questions or concerns

Continue to make healthy food choices and stay active. Maintain 3 servings of calcium foods per day (milk, cheese, yogurt).

Passed vision and hearing exam

Sports physical clearance provided for volleyball

Vaccines given today – Tdap, Meningococcal, & HPV – Vaccine education provided including possible side effects; VIS given. Return in 6–12 months for second HPV.

Routine screening labs ordered: Lipid panel, CMP

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370 | Appendix A

Sixteen-Year Well Check

Name: R.B.

DOB: 12/20/20XX

Age: 16 years

Accompanied By: Mother

Current Medications: None

Allergies: NKDA

Vital Signs:

Weight Height BMI Blood Pressure

Temp Pulse Respirations

123 lb 64.5 in. 20.8 112/72 98.4 82 16

Vision and Hearing Screen WNL – Corrected ® Yes ˛ No

HPI: 16-year-old female presents with mother for well check. Pt is a junior in high school and is doing very well in school. She plans to attend college after she graduates and wants to study physical therapy. Pt eats a variety of fruits, vegetables, meats, whole grains, cheese, yogurt, and some fish. Drinks 16 oz of 2% milk per day, no juice but has a soda once or twice a week. Pt is active for about 1 hour per day most days of the week. Onset of menses at age 12 – reports periods monthly/regular, cramping mild, no heavy bleeding. No parental concerns. HEADSSS screen performed with pt only and confidentiality discussed. Pt reports she is happy with her weight and has a healthy body image. She feels safe at home and gets along well with her parents and siblings most of the time. Denies abuse. Reports doing well in school and has positive peer relationships, denies bullying. Doing well in school, has good friends, and enjoys playing on the school volleyball team and also works out at a Crossfit gym. She denies smoking, alcohol, or drug use. She has had a couple of boyfriends but no very serious relationships and is currently single. She denies any sexual history and reports she knows how to protect herself against STIs and pregnancy. She denies symptoms of depression or suicidal ideations.

Family/Social History:

Father: Seasonal allergies MGM: HTN, hyperlipidemia

No smoking or use of illicit drugs in the home

Parental Concerns: None

Health Risk Assessment: ˛ HEADSSS – no concerns

Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing 2× Daily/Flossing ˛ Dental Visits Every 6 Months Dental Home: Dr. Sharman

Nutritional Screening: ˛ Nutritionally Balanced Diet ˛ 5 Servings Fruits & Veggies ˛ Soda/Energy Drinks

˛ Activity/Exercise (1 hr/day)

Developmental Surveillance: ̨ School Attendance ̨ Reading at Grade Level ̨ Dating ̨ Sexuality/Orientation

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Appendix A | 371

˛ Risk-Taking

Anticipatory Guidance Provided: ˛ Emergency/911 ˛ Violence/Gun Safety/Bullying ˛ Drowning/Sun Safety ˛ Car/Seat Belt/Driving Safety ˛ Safety at Home ˛ Sports/Injury Prevention ˛ Peer Refusal Skills ˛ Age Appropriate Limits ˛ Sexual Orientation/Dating ˛ Sex Education/STI/Resources ˛ Availability of Family Planning Services ˛ Social Interaction ˛ Tobacco/Alcohol/Drugs/Rx Drugs/Inhalants ˛ Risks of Tattoos/ Piercing ˛ Educational Goals/Activities ˛ Job/Career Planning ˛ Community Involvement ˛ After-School Activities/Supervision

Social-Emotional Health: ˛ Comfortable Body Image ˛ Mental Health Concerns ˛ Dealing with Stress ˛ Depression/Anxiety ˛ Decision-Making

Comprehensive Physical Exam:

Gen: Well appearing, alert

Skin: Normal turgor without rash or lesions

HEENT: Normocephalic. PERRL. Normal external ears, TMs normal bilaterally, normal external nose, septum midline, nares patent, neck supple with no mass or deformity, no cervical lymphadenopathy, mucous membranes moist, good dentition with no obvious caries.

Lungs: Unlabored respirations, symmetrical chest rise, normal RR, CTAB

CV: Regular rate and rhythm, no murmur

Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4

GU: Normal female external genitalia, Tanner stage V/V

MSK: Normal muscle tone and strength, spine straight, full ROM

Neuro: Alert, cranial nerves intact

Assessment:

Routine child health exam without abnormal findings – Z00.129

Pediatric well check/adolescent (12–17 years) – 99384

Plan:

VS and exam WNL, follow-up at 17-year well check, sooner with questions or concerns

Continue to make healthy food choices and stay active. Maintain 3 servings of calcium foods per day (milk, cheese, yogurt). Minimize soda intake to occasional treat.

Passed vision and hearing exam

HEADSSS assessment completed with no concerns, no STI screening needed

Vaccines given today – Meningococcal – Vaccine education provided including possible side effects; VIS given

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A Guide to Sexual History Taking

Appendix B

A Guide to Sexual History Taking

The importance of taking a sexual history

A sexual history is important for all patients to provide information that identifies those at risk for sexually transmitted disease, including HIV, to guide risk-reduction counseling, and to identify what anatomical sites are suitable for STD screening. This basic sexual history tool can be used by clinicians as a guide to determine the patient’s risk for STDs. This history can be taken by the clinician as part of the history and physical, or done by the patient as a self-administered questionnaire. This template may not be culturally appropriate for some patients, and it can be adjusted as needed.

Getting started and the 5 Ps

A. Getting started: introductory statements and questions

1. Teens. Care needs to be taken when introducing sensitive topics such as sexuality with teenagers. It is important to interview the teen alone and reinforce confidentiality. For teens, the sexual history can be incorporated into a broader risk assessment that addresses issues related to home, school, drug use, smoking, etc. Discussions should be appropriate for the teen’s developmental level.

“Now I am going to take a few minutes to ask you some sensitive questions that are important for me to help you be healthy. Anything we discuss will be completely confidential. I won’t discuss this with anyone, not even your parents, without your permission.”

“Some of my patients your age have started having sex. Have you had sex?” or “What are you doing to protect yourself from AIDS, HIV, or other STDs?”

If you identify that the teen is sexually active, you will want to continue with a more complete sexual history...

2. Adults. “Now I am going to take a few minutes to ask you some direct questions about your sexual health. These questions are very personal, but it is important for me to know so I can help you be healthy. I ask these questions to all of my patients regardless of age or marital status and they are just as important as other questions about your physical and mental health. Like the rest of this visit, this information is strictly confidential.”

B. The 5 Ps: Partners, sexual Practices, Past STDs, Pregnancy history and plans, and Protection from STDs

1. Partners. For sexual risk, it is important to determine the number and gender of a patient’s sexual partners. One should make no assumptions of partner gender in the initial history-taking. If multiple partners, explore for more specific risk factors, such as patterns of condom use and partner’s risk factors (i.e., other partners, injection drug use, history of STDs). If one partner, ask about length of the relationship and partner’s risk, such as other partners and injection drug use.

• “Do you have sex with men, women, or both?”

• “In the past 2 months, how many people have you had sex with?”

• “In the past 12 months, how many partners have you had?”

If the patient has sex with both men and women, repeat these questions for each specific gender.

2. Sexual Practices. In addition to determining the gender and number of partners, it is also important to ask about sexual practices and condom use. Asking about sex practices will guide risk-reduction strategies and identify anatomical sites from which to collect specimens for STD testing.

“I am going to be more explicit about the kind of sex you may have been having over the last year so I understand your risks for STDs.”

• “Do you have vaginal sex, meaning penis in vagina sex?” If answer is yes,

• “Do you use condoms: never, sometimes, most of the time, or always for this kind of sex?”

• “Do you have anal sex, meaning penis in rectum/anus sex?” If answer is yes,

• “Do you use condoms: never, sometimes, most of the time, or always for this kind of sex?”

• “Do you have oral sex, meaning mouth on penis/vagina?” If condom use is inconsistent,

• “In what situations, or with whom, do you not use condoms?”

3. Past history of STDs. A history of prior gonorrhea or chlamydia infections increases a person’s risk for repeat infection. Recent past STDs indicate higher risk behavior. • “What STDs have you had in the past, if any?”

• “Have you ever had an STD, such as chlamydia, gonorrhea, herpes, or warts?” If answer is yes,

• “Do you know what the infection was and when it was?”

• “Have any of your partners had an STD?” If answer is yes,

• “Do you know what the infection was and when it was?”

(Continued)

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374 | Appendix B

4. Pregnancy plans. Based on partner information already obtained, you may determine that the patient is at risk for becoming pregnant or causing a pregnancy. If so, determine first whether pregnancy is desired.

• “What are your current plans or desires regarding pregnancy?” (Women)

• “Are you concerned about getting pregnant or getting your partner pregnant?”

• “Are you trying to get pregnant?” (Women)

• “Are you and a partner trying to get pregnant?” (Men) If answer is no,

• “What are you doing to prevent a pregnancy?”

5. Protection from STDs • “What do you do to protect yourself from sexually transmitted diseases and HIV?”

With this open-ended question, you allow different avenues of discussion: condom use, monogamy, patient self-perception of risk, and perception of partner’s risk. If you have determined that the patient has had one partner in the past 12 months and that partner has had no other partners, infrequent or no condom use may not warrant risk-reduction counseling. Regardless of the patient’s risk behavior, if the patient is a woman and is 25 or younger, routine screening for chlamydia is recommended annually.

C. Additional questions to identify HIV and hepatitis risk. Immunization history for hepatitis A and B can be noted at this point, as well as past HIV testing. Hepatitis A immunization is recommended for men who have sex with men (MSM) and intravenous drug users (IDU).

• “Have you or any of your partners ever injected drugs?”

• “Have you or any of your partners ever had sex with prostitutes?”

• “Have you ever gotten hepatitis B vaccine (all 3 doses)?”

• “Have you ever gotten hepatitis A vaccine (2 doses)?” (only MSM, IDU)

• “Have you ever been tested for HIV, the virus that causes AIDS?”

D. Finishing up. By the end of this section of the interview, the patient may have come up with information or questions that she/he was not ready to discuss earlier.

• “Is there anything else about your sexual practices that I need to know about to ensure you good health care?”

• “Do you have any questions?”

At this point, review and reinforce positive, protective behaviors. After reinforcing positive behavior, it is appropriate to address specific concerns regarding higher-risk practices. Your expression of concern can then lead to risk-reduction counseling or a counseling referral.

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ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

Appendix C

Institute for Safe Medication Practices

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations

Abbreviations Intended Meaning Misinterpretation Correction µg Microgram Mistaken as “mg” Use “mcg”

AD, AS, AU Right ear, left ear, each ear Mistaken as OD, OS, OU (right eye, left eye, each eye) Use “right ear,” “left ear,” or “each ear” OD, OS, OU Right eye, left eye, each eye Mistaken as AD, AS, AU (right ear, left ear, each ear) Use “right eye,” “left eye,” or “each eye”

BT Bedtime Mistaken as “BID” (twice daily) Use “bedtime” cc Cubic centimeters Mistaken as “u” (units) Use “mL” D/C Discharge or discontinue Premature discontinuation of medications if D/C (intended to mean

“discharge”) has been misinterpreted as “discontinued” when followed by a list of discharge medications

Use “discharge” and “discontinue”

IJ Injection Mistaken as “IV” or “intrajugular” Use “injection” IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS” HS

Half-strength

At bedtime, hours of sleep

Mistaken as bedtime

Mistaken as half-strength

Use “half-strength” or “bedtime”

IU** International unit Mistaken as IV (intravenous) or 10 (ten) Use “units” o.d. or OD Once daily Mistaken as “right eye” (OD-oculus dexter), leading to oral liquid

medications administered in the eye Use “daily”

OJ Orange juice Mistaken as OD or OS (right or left eye); drugs meant to be diluted in orange juice may be given in the eye

Use "orange juice"

Per os By mouth, orally The “os” can be mistaken as “left eye” (OS-oculus sinister) Use “PO,” “by mouth,” or “orally” q.d. or QD** Every day Mistaken as q.i.d., especially if the period after the “q” or the tail of

the “q” is misunderstood as an “i” Use “daily”

qhs Nightly at bedtime Mistaken as “qhr” or every hour Use “nightly” qn Nightly or at bedtime Mistaken as “qh” (every hour) Use “nightly” or “at bedtime”

q.o.d. or QOD** Every other day Mistaken as “q.d.” (daily) or “q.i.d.” (four times daily) if the “o” is poorly written

Use “every other day”

q1d Daily Mistaken as q.i.d. (four times daily) Use “daily” q6PM, etc. Every evening at 6 PM Mistaken as every 6 hours Use “daily at 6 PM” or “6 PM daily”

SC, SQ, sub q Subcutaneous SC mistaken as SL (sublingual); SQ mistaken as “5 every;” the “q” in “sub q” has been mistaken as “every” (e.g., a heparin dose ordered “sub q 2 hours before surgery” misunderstood as every 2 hours before surgery)

Use “subcut” or “subcutaneously”

ss Sliding scale (insulin) or ½ (apothecary)

Mistaken as “55” Spell out “sliding scale;” use “one-half” or “½”

SSRI

SSI

Sliding scale regular insulin

Sliding scale insulin

Mistaken as selective-serotonin reuptake inhibitor

Mistaken as Strong Solution of Iodine (Lugol's)

Spell out “sliding scale (insulin)”

i/d One daily Mistaken as “tid” Use “1 daily” TIW or tiw 3 times a week Mistaken as “3 times a day” or “twice in a week” Use “3 times weekly”

U or u** Unit Mistaken as the number 0 or 4, causing a 10-fold overdose or greater (e.g., 4U seen as “40” or 4u seen as “44”); mistaken as “cc” so dose given in volume instead of units (e.g., 4u seen as 4cc)

Use “unit”

UD As directed (“ut dictum”) Mistaken as unit dose (e.g., diltiazem 125 mg IV infusion “UD” misin- terpreted as meaning to give the entire infusion as a unit [bolus] dose)

Use “as directed”

Dose Designations and Other Information

Intended Meaning Misinterpretation Correction

Trailing zero after decimal point (e.g., 1.0 mg)**

1 mg Mistaken as 10 mg if the decimal point is not seen Do not use trailing zeros for doses expressed in whole numbers

“Naked” decimal point (e.g., .5 mg)**

0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero before a decimal point when the dose is less than a whole unit

Abbreviations such as mg. or mL. with a period

following the abbreviation

The period is unnecessary and could be mistaken as the number 1 if written poorly

Use mg, mL, etc. without a terminal period

he abbreviations, symbols, and dose designations found in this table have been reported to ISMP through the ISMP

National Medication Errors Reporting Program (ISMP MERP) as being frequently misinterpreted and involved in harmful medication errors. They should NEVER be used when commu-

nicating medical information. This includes internal communica- tions, telephone/verbal prescriptions, computer-generated labels, labels for drug storage bins, medication administration records, as well as pharmacy and prescriber computer order entry screens.

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376 | Appendix C

Institute for Safe Medication Practices

Dose Designations and Other Information

Intended Meaning Misinterpretation Correction

Drug name and dose run together (especially problematic for drug names that end in “l” such as Inderal40 mg;

Tegretol300 mg)

Inderal 40 mg

Tegretol 300 mg

Mistaken as Inderal 140 mg

Mistaken as Tegretol 1300 mg

Place adequate space between the drug name, dose, and unit of measure

Numerical dose and unit of measure run together

(e.g., 10mg, 100mL)

10 mg

100 mL

The “m” is sometimes mistaken as a zero or two zeros, risking a 10- to 100-fold overdose

Place adequate space between the dose and unit of measure

Large doses without properly placed commas

(e.g., 100000 units; 1000000 units)

100,000 units

1,000,000 units

100000 has been mistaken as 10,000 or 1,000,000; 1000000 has been mistaken as 100,000

Use commas for dosing units at or above 1,000, or use words such as 100 "thousand" or 1 "million" to improve readability

Drug Name Abbreviations Intended Meaning Misinterpretation Correction To avoid confusion, do not abbreviate drug names when communicating medical information. Examples of drug name abbreviations involved in medication errors include:

APAP acetaminophen Not recognized as acetaminophen Use complete drug name ARA A vidarabine Mistaken as cytarabine (ARA C) Use complete drug name AZT zidovudine (Retrovir) Mistaken as azathioprine or aztreonam Use complete drug name CPZ Compazine (prochlorperazine) Mistaken as chlorpromazine Use complete drug name DPT Demerol-Phenergan-Thorazine Mistaken as diphtheria-pertussis-tetanus (vaccine) Use complete drug name DTO Diluted tincture of opium, or

deodorized tincture of opium (Paregoric)

Mistaken as tincture of opium Use complete drug name

HCl hydrochloric acid or hydrochloride

Mistaken as potassium chloride (The “H” is misinterpreted as “K”)

Use complete drug name unless expressed as a salt of a drug

HCT hydrocortisone Mistaken as hydrochlorothiazide Use complete drug name HCTZ hydrochlorothiazide Mistaken as hydrocortisone (seen as HCT250 mg) Use complete drug name

MgSO4** magnesium sulfate Mistaken as morphine sulfate Use complete drug name MS, MSO4** morphine sulfate Mistaken as magnesium sulfate Use complete drug name

MTX methotrexate Mistaken as mitoxantrone Use complete drug name NoAC novel/new oral anticoagulant No anticoagulant Use complete drug name PCA procainamide Mistaken as patient controlled analgesia Use complete drug name PTU propylthiouracil Mistaken as mercaptopurine Use complete drug name T3 Tylenol with codeine No. 3 Mistaken as liothyronine Use complete drug name TAC triamcinolone Mistaken as tetracaine, Adrenalin, cocaine Use complete drug name TNK TNKase Mistaken as “TPA” Use complete drug name

TPA or tPA tissue plasminogen activator, Activase (alteplase)

Mistaken as TNKase (tenecteplase), or less often as another tissue plasminogen activator, Retavase (retaplase) Use complete drug names

ZnSO4 zinc sulfate Mistaken as morphine sulfate Use complete drug name Stemmed Drug Names Intended Meaning Misinterpretation Correction

“Nitro” drip nitroglycerin infusion Mistaken as sodium nitroprusside infusion Use complete drug name “Norflox” norfloxacin Mistaken as Norflex Use complete drug name “IV Vanc” intravenous vancomycin Mistaken as Invanz Use complete drug name Symbols Intended Meaning Misinterpretation Correction

Dram

Minim

Symbol for dram mistaken as “3”

Symbol for minim mistaken as “mL”

Use the metric system

x3d For three days Mistaken as “3 doses” Use “for three days” > and < More than and less than Mistaken as opposite of intended; mistakenly use incorrect

symbol; “< 10” mistaken as “40” Use “more than” or “less than”

/ (slash mark) Separates two doses or indicates “per”

Mistaken as the number 1 (e.g., “25 units/10 units” misread as “25 units and 110” units)

Use “per” rather than a slash mark to separate doses

@ At Mistaken as “2” Use “at” & And Mistaken as “2” Use “and” + Plus or and Mistaken as “4” Use “and” ° Hour Mistaken as a zero (e.g., q2° seen as q 20) Use “hr,” “h,” or “hour”

Ф or zero, null sign Mistaken as numerals 4, 6, 8, and 9 Use 0 or zero, or describe intent using whole words

**These abbreviations are included on The Joint Commission’s “minimum list” of dangerous abbreviations, acronyms, and symbols that must be included on an organization’s “Do Not Use” list, effective January 1, 2004. Visit www.jointcommission.org for more information about this Joint Commission requirement.

ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (continued)

© ISMP 2015. Permission is granted to reproduce material with proper attribution for internal use within healthcare organizations. Other reproduction is prohibited without written permission from ISMP. Report actual and potential medication errors to the ISMP National Medication Errors Reporting Program (ISMP MERP) via the Web at www.ismp.org or by calling 1-800-FAIL-SAF(E).

www.ismp.org

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377

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Bobb A, Gleason K, Husch M, Geinglass J, Yarnold PR, Noskin GA. The epidemiology of prescribing errors: the potential impact of computerized prescriber order entry. Arch Intern Med. 2004;164:785‒791.

California Health Care Foundation. Computerized physician order entry (CPOE) is succeeding in community hospitals. http://www.chcf.org/media/press-releases/2003/computerized- physician-order-entry-cpoe-is-succeeding-in-community- hospitals. Accessed October 1, 2017.

Cartmill RS, Walker JM, Blosky MA, et al. Impact of electronic order management on the timeliness of antibiotic administration in critical care patients. Int J Med Inform. 2012;81(11):782‒791.

Centers for Disease Control and Prevention. 2006 national hospital discharge survey. National health statistics reports; No. 5. Published July 2008. http://www.cdc.gov/nchs/data/ nhsr/nhsr005.pdf. Accessed September 4, 2009.

Centers for Medicare and Medicaid Services. Title 42-Public Health; Chapter 4, Section 482.24. https://www.cms.gov/ Regulations-and-Guidance/Guidance/Manuals/downloads/ som107ap_a_hospitals.pdf. Accessed October 1, 2017.

Charles K, Cannon M, Hall R, Coustasse A. Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events? Perspect Health Inf Manag. 2014;11(Fall).

Classen DC, Avery AJ, Bates DW. Evaluation and certification of computerized provider order entry systems. J Am Inform Assoc. 2007;14(1):48‒55.

Cornish PL, Knowles SR, Marchesano R, et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005;65(4):424‒429.

Devine EB, Williams EC, Martin DP, et al. Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment. BMC Med Inform Decis Mak. 2010;10(72):72‒83.

Dixon BE, Zafar A. Inpatient Computerized Provider Order Entry: Findings from the AHRQ Health IT Portfolio (Pre- pared by the AHRQ National Resource Center for Health IT). AHRQ publication 09-0031-EF. Rockville, MD: Agency for Healthcare Research and Quality. Published January 2009. Accessed October 1, 2017.

Greenwald JL, Halasyamani L, Greene J, et al. Making inpatient medication reconciliation patient centered, clinically relevant and implementable: a consensus statement on key principles and necessary first steps. J Hosp Med. 2010;5:477‒485.

Institute for Safe Medication Practices. List of error-prone abbreviations, symbols, and dose designations. http://www .ismp.org/tools/errorproneabbreviations.pdf. Accessed October 1, 2017.

Kaushal R, Shojania KG, Bates DW. Effects of computerized physician order entry and clinical decision support systems

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Kohn LT, Corrigan JM, Donaldson MS, eds. Institute of Medi- cine Report. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.

Magid S, Forrer C, Shaha S. Duplicate orders: an unintended consequence of computerized provider/physician order entry (CPOE) implementation: analysis and mitigation strategies. Appl Clin Inform. 2012;4:377‒391.

Mattison ML, Afonso KA, Ngo LH, Mukamal KJ. Preventing potentially inappropriate medication use in hospitalized older patients with a computerized provider order entry warning system. Arch Intern Med. 2010;170(15):1331‒1336.

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The Leapfrog Group. Medication safety: data by hospital on nationally standardized metrics. http://www.leapfroggroup. org/sites/default/files/Files/Castlight%20Leapfrog%20Med- ication%20Safety%20Report%202017_Final.pdf. Accessed October 3, 2017.

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Zimlichman EC, Keohane C, Franz WL, et al. Return on in- vestment for vendor computerized physician order entry in four community hospitals: the importance of decision support. Jt Comm J Qual Patient Saf/Joint Commission Resources. 2013;39(7):312‒318.

Chapter 11 Centers for Medicare and Medicaid Services. Electronic

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Samaritan GA. Standard of care deviation results in patient’s death. Copy & paste documentation not helpful to the defense. J Med Assoc Ga. 2010;99(2):32‒33.

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Centers for Disease Control and Prevention. National hospital discharge survey: 2007 summary. National Health Statistics Report 29. October 26, 2010. Accessed October 1, 2017.

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A Abbreviations

common prescription abbreviations, 203 dangerous abbreviations to avoid, 204 Error-Prone Abbreviations, Symbols

and Dose Designations, Appendix C errors, 195, 199, 201 prescription writing, 203

Abdomen, examination of, 30 Abdominal aortic aneurysm

screening, 138 Abducens nerve, 30 Abortus, defined, 80 Abuse, child, 102, 105 Acoustic nerve, 30 Activities of daily living, 156 Activity

admission orders, 227 level, in discharge order, 286 perioperative orders, 230

AD CAVA DIMPLS mnemonic, 225–226, 230

Admission orders, 223, 225–229 Admit notes, 237 Admitting patient to hospital

admission history and physical examination, 218–221

admission orders, 223, 225–229 overview of, 217 surgical history and physical

examination, 221–223, 260, 261–263 Adolescents, 102 Advance directives, 165 Adverse drug events

electronic prescribing, 203 hospitalized patients, 228, 234 medications, 201

Against medical advice, patient leaving hospital, 291, 293

Agency for Healthcare Research and Quality (AHRQ), 137

Ages and Stages Questionnaires (ASQ-3), 99

Age-specific physical examinations, 106, 107–108

Alcohol consumption, 130–131 Alcoholism, 131 Alcohol Use Disorders Identification Test

(AUDIT), 131, 132

Allergic/immunologic system, review of, 29 Allergies

admission orders, 228 comprehensive history and physical

examination, 25–26 drug, 25 in medication list, 176 perioperative orders, 230

Ambulatory medical care, 125 American Academy of Pediatrics (AAP), 94 American College of Physicians (ACP),

186–187 American Health Information

Management Association (AHIMA), 186

American Medical Association, 5, 186 American Recovery and Reinvestment

Act, 9 Americans with Disabilities Act, 219 Anorexia nervosa, 106 Anticipatory guidance, 100–102 Anti-emetics, 232 Apgar scoring, 86, 87 ASQ-3 (Ages and Stages

Questionnaires), 99 Assessments

in admission history and physical examination, 220

Assessment portion of SOAP notes, 52–54, 257

balance and mobility, 162 BRCA risk assessment and genetic

counseling/testing, 137 cardiopulmonary, 163 cardiovascular disease, 138 cognitive, 162 comprehensive history and physical

examination, 32 general, 48, 220 geriatric risk factors, 153–162 medical admissions, 258 Mini Nutritional Assessment—Short

Form (MNA-SF), 156, 159 risk factor assessment through history

taking, 153–160 risk factor assessment through physical

examination, 160–162 sexually transmitted infections, 137, 138 in surgical history and physical

examination, 223

Tinetti Performance Oriented Mobility Assessment tool, 162

Asthma, genetic tendency, 135 Asymmetrical tonic neck reflex, 108 Attending physician, 289 AUDIT (Alcohol Use Disorders

Identification Test), 131, 132 Authorization, to disclose health

information, 11

B Balance assessment, 162 Bayley Scales of Infant and Toddler

Development (Bayley-III), 99 Beers criteria, 155 Berg Balance Test, 162 Billing information, 179 Bishop score, 81–82 Blood product transfusions, 134 BMI. See Body mass index (BMI) Body mass index (BMI)

pediatric screenings, 94, 97–98 risk-factor identification using,

128–129 BRCA risk assessment and genetic

counseling/testing, 137 Breast

cancer screening, 137 examination of, 30 genetic tendency for cancer, 135

Bright Futures program, 93–94, 99

C CAGE questionnaire, 130–131 Cancer

breast, 135, 137 cervical, 137 colon, 137 colorectal, 135 genetic tendency, 135 oral, 134 ovarian, 135 screening mammography, 126

CAPTA (Child Abuse Prevention and Treatment Act), 102

Cardiopulmonary assessment, pre- operative evaluation of older adults, 163

Index

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388 | Index

Cardiovascular system examination, 30 genetic tendency for disease, 135 review of, 28, 107 risk assessment for disease, 138

Catheter care, 233 CDC. See Centers for Disease Control and

Prevention (CDC) CDSS (Clinical Decision Support

System), 205–206, 235 CDT (clock-drawing test), 162 Centers for Disease Control and

Prevention (CDC) body mass index, 94 growth standards, 94 medical records content for hospitalized

patients, 217 older adult vaccinations, 162 oral health, 134 vaccinations, 100

Centers for Medicare and Medicaid Services (CMS)

admission history and physical examination, 218

comprehensive history and physical examination, 24

documentation guidelines, 3 electronic prescribing, 204 EMR note review, 260 prescription writing, 197 telemedicine, 186

Cerebellum, 30 Cervical cancer screening, 137 Cervix score, 81–82 Chief complaint, 24–25, 218, 221 Child abuse, 102, 105 Child Abuse Prevention and Treatment

Act (CAPTA), 102 Childhood Maltreatment Interview

Schedule—Short Form (CMIS-SF), 105–106

Childhood obesity, 97 Childhood Trauma Questionnaire, 105 Chronic condition, 7 Cigarette smoking, 129–130 Civil Rights Act of 1964, 219 Clear liquid diet, 232 Clinical Decision Support System

(CDSS), 205–206, 235 Clock-drawing test (CDT), 162 CMS. See Centers for Medicare and

Medicaid Services (CMS) Coagulation studies, 179 Code of Federal Regulations (CFR),

medical records content for hospitalized patients (42 CFR 482.24), 217

Codes. See Current Procedural Terminology codes

Cognitive assessment, 162 Colon cancer screening, 137 Colorectal cancer, genetic, 135 Communication with patient, 183–187.

See also Outpatient charting and communication

Comorbid conditions, 220

Comprehensive history and physical examination

assessments, 32 components of, 24 diagnostic studies, 32 differential diagnosis, 32 history. See History laboratory studies, 32 physical examination, 29–31 plan of care, 32 problem list, 32 sample, 32–35 uses of, 23

Computer-based patient record, 8 Computerized Physician Order Entry

(CPOE), 235–237 Condition

admission orders, 227 perioperative orders, 230

Confidentiality, social media, 188 Consent, to disclose health information,

11, 273 Consultation letter, 182, 184 Consultations, 54–55, 182 Consulting provider, 182 Consult note, 266–270 Container information section, of

prescription, 201 Contraceptive counseling and methods, 137 Controlled substances

closed distribution system, 196, 206 Controlled Substances Act (CSA), 196 description of, 199 e-prescribing, 206 prescription writing for, 201, 205

Coronary heart disease, 135 Counseling, health, 139 Covered entities, 11 CPOE (Computerized Physician Order

Entry), 235–237 Cranial nerves, 30, 108 Cultural history, 27 Current Procedural Terminology codes

description of, 5 evaluation and management services, 5–6 fraud, 7 minutes used for medical discussion, 184

D Daily catheter care, 233 Daily orders, 260, 264–266 Daily progress note

content of, 257–260 description of, 257 medical admissions, 257–259 surgical admissions, 260, 261–263

Daily wound care, 233 DDST-II (Denver Developmental

Screening Test II), 99 DEA. See Drug Enforcement Agency

(DEA) Deferral of examination, 139 Definitive diagnosis, 52–53 Delivery note, 83–86 Demographic information, 80, 179

Denver Developmental Screening Test II (DDST-II), 99

Department of Health and Human Services (HHS), 3, 5, 219

Depression, 160, 161 Developmental screening, 98–99 Diabetes mellitus

genetic tendency, 135 screening, 137, 138 Type 2, 97–98

Diagnosis admission orders, 227 perioperative orders, 230

Diagnostic studies admission history and physical

examination, 220 admission orders, 229 comprehensive history and physical

examination, 32 postoperative, 233–234 pre-operative evaluation of older

adults, 163 surgical history and physical

examination, 223 Diagnostic tests

definitive diagnosis, 52–53 prenatal care documentation, 82 screening, 126 SOAP note documentation of results of,

50, 54 Diet

discharge order, 286 postoperative, 230, 232 risk factor identification, 126, 128

Diet order, 228, 230, 232 Differential diagnosis

admission history and physical examination, 220

comprehensive history and physical examination, 32

SOAP notes, 52, 53 surgical history and physical

examination, 223 Discharge orders, 285–288 Discharge summary

admitting and discharge diagnosis, 288 attending physician, primary provider,

and consulting physician, 289 condition at discharge, 291 dates of admission and discharge, 288 description of, 288, 289 disposition, 291 follow-up instructions, 291 history, 289–290 hospital course in, 290 instructions, 291 laboratory values, 289–290 medications, 291 physical examination findings, 289–290 procedures, 289 sample, 292–293

Disclosure, of health information, 11 Disease prevention

CDC. See Centers for Disease Control and Prevention (CDC)

prenatal care documentation, 83

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Index | 389

preventive care, 125 purpose of, 55

Disposition, in discharge order, 286 Documentation

alterations, 3 analyzing, 47–48 correcting, 3 evolution of, 1–2 general principles, 3–5 importance of, 1 legal considerations for, 2–3 medical considerations for, 2 medical records, ICD guidelines, 173 outpatient charting and communication,

183–187 patient counseling, 28 patient education, 55 perinatal and postpartum care, 83–88 prenatal care, 80–83 preventive care visits, 126–139 proven diagnosis, 53 purposes of, 3

Dose designations, Appendix C Downcoding, 7 Drug Abuse Screening Test, 131, 133 Drug allergies, 25 Drug Enforcement Agency (DEA)

controlled substances, 196, 199, 206 e-prescribing, 196 prescription drug abuse, 197, 199

Drug names abbreviations, 199 look-alike and sound-alike, 195

E Ear examination, 30 Early and Periodic Screening, Diagnosis,

and Treatment program (EPSDT), 93 Ears, nose, and mouth/throat, review of, 28 Eating disorders, 106 E-cigarettes, 102 Education, Internet sources for, 187 EHR (electronic health record), 8 Electronic health record (EHR), 8 Electronic medical records (EMR)

barriers to, 9, 206 benefits of, 8–9 definition of, 8 diagnostic test findings included in, 179 e-mailing of, 186–187 health-care delivery functions of, 8 interoperability of, 9 meaningful use of, 9–10 system qualifications, 204–205

Electronic nicotine delivery systems (ENDS), 102

Electronic patient record (EPR), 8 Electronic prescribing

adverse drug event reductions using, 203 barriers to, 206 benefits of, 205–206 certification issues, 206 components of, 204 cost considerations, 206 definition of, 203

description of, 8–9 error rates, 195–196 errors associated with, 206 federal initiatives for, 204 growth of, 206 lack of standards for, 206 qualified, 204–205 safety benefits of, 204, 205

Electronic Prescriptions for Controlled Substances rule, 206

E-mail, 185–187 benefits of, 185 concerns of, 185–186 provisions for using, 186–187

Emotional abuse, 102, 105 EMR. See Electronic medical records

(EMR) Endocrine system, review of, 29 Environmental allergies, 25 EPR (electronic patient record), 8 EPSDT (Early and Periodic Screening,

Diagnosis, and Treatment) program, 93 Evaluation and management services,

5–6, 218 Exercise, 126 Eye examination, 29 Eyes, review of, 28

F Facial nerve, 30 Falls, 160 Family Healthware, 135 Family history

in admission history and physical examination, 219

description of, 26 risk-factor identification based on, 135 in surgical history and physical

examination, 221 Federation of State Medical Boards

(FSMB), 186–187 Female genitourinary system, review of, 108 Fever, postoperative, 260 FIST screening, 102, 104 Five Ws, 260, 264 Flow sheets, 179, 180 Follow-up care, in discharge order, 287 Follow-up instructions, 56, 58 Food allergies, 25, 176 Food and Drug Administration (FDA),

confusion concerning drug names, 195

Food diary, 128 Fraud, 7 Full liquid diet, 232 Full operative report, 271 Functional impairment, 156

G Gait, 162 Galant’s reflex, 108 GAPS (Guidelines for Adolescent

Preventive Services), 102 Gastrointestinal system, review of, 28, 107 Gender-specific screening, 136–139

General assessments, 48, 220 Generic substitution section, of

prescription, 201 Genetic diseases, 99, 135 Genitalia, examination of, 30 Genitourinary system, review of, 28 Geriatric Depression Scale (GDS), 160, 161 Geriatric Health Questionnaire, 153,

154–155 Geriatric risk factors. See also Older adult

preventive care visits assessment of, 153–162 cognition, 162 depression, 160 functional impairment, 156 gait, 162 mobility, 162 nutrition, 156–159 sensory deficits, 159–160

Geriatric syndrome, 160 Glossopharyngeal nerve, 30 Growth charts, 94, 96–97 Growth screening, 94, 97–98 Guidelines for Adolescent Preventive

Services (GAPS), 102 Gynecological examination, 30

H HDDA (Hearing-Dependent Daily

Activities) Scale, 159–160 Head circumference, 94 Head examination, 29 Healthcare Information and Management

Systems Society (HIMSS), 9 Health-care power of attorney, 165 Health education and counseling, 139 Health Information Technology for

Economic and Clinical Health Act (HITECH), 9–10

Health Insurance Portability and Accountability Act (HIPAA)

authorization, 11 background, 10 consent, 11 covered entities, 11 description of, 10 electronic health-care transitions, 10 electronic PHI communications, 186 electronic protected health information

provisions, 186 Health Insurance Portability provision

of, 10 individual rights, 11–12 minors, 12 Notice of Privacy Practices, 12–13 patient rights, 11–12 penalties for violating, 13 privacy policy elements, 13 Privacy Rule, 10–13 privacy violations and penalties, 13 protected health information,

11, 13, 186 security safeguards, 13–14 summary of, 14 violation of, 13

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390 | Index

Health literacy, 126 Health maintenance, 125, 219 Health promotion

defined, 55 prenatal care documentation, 83

Health Resources and Services Administration (HRSA), 94

Hearing-Dependent Daily Activities (HDDA) Scale, 159–160

Hearing loss, 159, 161–162 HEEADSSS, 102–104 HEENT, 29–30, 107 Hematologic system, review of, 29 Hepatitis C screening, 137 HHS (Department of Health and Human

Services), 3, 5, 219 HIPAA. See Health Insurance Portability

and Accountability Act (HIPAA) History

admission history and physical examination, 218–221

chief complaint, 24–25 comprehensive. See Comprehensive

history and physical examination family history, 26, 135, 219 identification section of, 24 medical admission, 218–221 older adult risk factors, 153–160 past medical history, 25–26,

218–219, 221 review of systems, 28–29, 219–220 sexual, 132–133 social history, 26–27 surgical history and physical

examination, 221–223 History of the present illness (HPI), 25,

218, 221 HITECH (Health Information

Technology for Economic and Clinical Health Act), 9–10

HIV screening, 137 Hospice, 166 Hospital

admitting patient to. See Admitting patient to hospital

adverse drug events in hospitalized patients, 228, 234

Code of Federal Regulations (CFR), medical records content for hospitalized patients (42 CFR 482.24), 217

hospital course in discharge summary, 290

The Joint Commission, medical records content for hospitalized patients, 216

medical records content for hospitalized patients, 217

patient elopement from, 293–294 patient leaving, against medical advice,

291, 293 Hospital course, 290 HPI (history of the present illness), 25,

218, 221 Hyperlipidemia, 135 Hypertension screening, 137 Hypoglossal nerve, 30

I ICD. See International Classification of

Diseases (ICD) ICD-10, 6 Identification section, of history, 24 Immunizations See also vaccinations

in admission history and physical examination, 219

in adults, 139 in children, 100

Immunologic system, review of, 29 Indication section, of prescription, 200 Inpatient care

consult note, 266–270 daily orders, 260, 264–266 daily progress note, 257–260, 261–263 full operative note, 271 operative note, 271 procedure note, 272–273

Inscription section, of prescription, 199–200

Institute for Safe Medical Practice (ISMP), 234–235

Instrumental activities of daily living, 156

Insurance, hospice services, 166 Integumentary system, review of, 29 International Classification of Diseases

(ICD) description of, 5 evaluation and management services,

6–7 ICD-10, 6 medical record documentation, 173

Internet for medical education, 187 Interoperability, of electronic medical

records, 9 Interpreter for H&P, 25 Interpretive services, 219 Interventions

admission orders, 228 done during the visit, 50–51 not done, 226 perioperative orders, 232

Intimate partner violence (IPV), 133–134 Intravenous therapy, 228 IPV screening and counseling, 137

J The Joint Commission, medical records

content for hospitalized patients, 217

K Katz Index, 156

L Laboratory data, prenatal care

documentation, 82 Laboratory studies

in admission history and physical examination, 220

in admission orders, 229 description of, 32 outpatient, 179

in pediatric preventive care visits, 99 postoperative, 233–234 pre-operative evaluation of older

adults, 163 shorthand for documenting results of,

261–263 in surgical history and physical

examination, 223 Laboratory tests, 54 Laterality, 48 Latex allergies, 25 Lawton IADL Scale, 156 Lead exposure screening, 99 Legal considerations, 2–3 Level of service, 5–6 Living will, 165 Lymphatic system, review of, 29

M Male genitourinary system, review of, 107 Malpractice

documentation involving laterality, 48 lack of patient counseling on risks of

negative health habits, 28 patient education documentation, 55 prenatal test result documentation, 82 professional liability for vaccinations,

100 Mammogram, 126, 137 Maternal and Child Health Bureau

(MCHB), 94 Maternal history, prenatal care

documentation, 80–81 Medicaid, 186 Medical admissions, 257–259

assessment, 258 objective, 258 plan, 259 subjective, 257–258

Medical billing and coding, 5–7, 179 Medical history

description of, 127–128 pediatric, 94, 95

Medical records credibility uses of, 2 dictating of, 83, 237, 271, 288 prior, 183

Medicare e-mail communications, 186 hospice services, 166

Medicare Improvements for Patients and Providers Act, 204

Medicare Modernization Act of 2003, 204 Medication history for hospital admission,

218 Medication list

description of, 176 in past medical history, 25 sample, 177

Medications in admission order, 228–229 adverse events, 201 in discharge order, 286–287 list of. See Medication list older adults, 153, 155

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Index | 391

perioperative, 232 reconciliation, 228–229 symptomatic, 229

Medicolegal alert adverse medication events, 201 consent, 273 copy/paste notes, 259–260 deferred examination, 139 follow-up instructions, 288 fraud, 7 health-care POA, 165 interpreter services, discrimination, 219 intervention not done, 266 laboratory tests during pregnancy, 82 lack of patient counseling on risks of

negative health habits, 28 laterality, 48 medication list, 176 patient education documentation, 55 patient noncompliance, 182 proven diagnosis documentation, 53 vaccination refusal, 100

Men, screening for, 138–139 Mental status, examination of, 30 Mini-Cog test, 162 Mini Nutritional Assessment—Short

Form (MNA-SF), 156, 159 Minors, 12 Mnemonics, 25, 26 Mobility assessment, 162 Moro reflex, 108 Motor strength testing, 30 Mouth, review of, 107 Mouth examination, 30 Muscle strength grading, 30 Musculoskeletal examination, 30, 109 Musculoskeletal system, review

of, 29, 108 “My Family Health Portrait,” 135

N Narrative format, for documenting

objective information, 47–48, 49 National Child Abuse Hotline, 106 National Childhood Vaccine Injury Act

(NCVIA), 100 National ePrescribing Patient Safety

Initiative, 206 National Health and Nutrition

Examination Survey (NHANES), 97 National Institute of Drug Abuse

Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA Modified ASSIST), 131

Neck, review of, 107 Neck examination, 30 Neglect, 102, 105 Neurological examination, 30–31 Neurological reflexes, 106 Neurological system, review of, 29, 108 New Ballard score, 87 Newborn physical examination, 87, 88 NHANES (National Health and

Nutrition Examination Survey), 97 NIDA Modified ASSIST, 131

Noncompliance with medical treatment, 179, 181–182

Noncontrolled substances description of, 199 prescription writing for, 199–201

Nonpharmacological treatment, 55 Nose examination, 30 Notice of Privacy Practices, 12–13 NPO, 232 Nutrition

information, 27 Mini Nutritional Assessment—Short

Form (MNA-SF), 156, 159 National Health and Nutrition

Examination Survey (NHANES), 97 Nutritional Health Checklist, 157–158 Nutrition Checklist warning signs, 158 in older adults, 156–159 prenatal care documentation, 83 risk-factor identification, 126, 128

O Occupational history, 134 Occupational Safety and Health

Administration (OSHA), 134 Oculomotor nerve, 30 Office for Civil Rights (OCR), 219 Older adult preventive care visits. See also

Geriatric risk factors advance directives, 165 balance and mobility assessment, 162 cognitive assessment, 162 functional impairment, 156 Geriatric Health Questionnaire, 153,

154–155 geriatric syndromes, 160 hospice and palliative care, 166 medication use, 153, 155 mental health screening, 160, 161 nutrition, 156–159 overview, 153 pre-operative evaluations, 162–164 risk factor assessment through history

taking, 153–160 risk factor assessment through physical

examination, 160–162 sensory deficit screening, 159–160 sensory examinations, 161–162 USPSTF screening recommendations,

162 Olfactory nerve, 30 Operative note, 271 Optic nerve, 30 Oral cancer, 134 Oral health, 134 Orders

admission, 223, 225–229 Computerized Physician Order Entry

(CPOE), 235–237 daily, 260, 264–266 diet, 228, 230, 232 discharge, 285–288 perioperative, 229–234 postanesthesia care unit, 229, 231 postoperative, 230, 234

preoperative, 229, 230 special instruction, 229, 234

OSHA (Occupational Safety and Health Administration), 134

Osteoporosis caused by eating disorders, 106 genetic tendency, 135 screening, 137

Outpatient charting and communication advance directives, 165 billing information, 179 demographic information, 179 documentation of communication,

183–187 flow sheets, 179, 180 medication list, 176–178 noncompliance with medical treatment,

179, 181–182 overview of, 173 patient portal, 187 prior medical records, 183 problem list, 173–176 referrals, 182, 183

Ovarian cancer, 135 Overweight, 97

P Palliative care, 166 Palmar grasp reflex, 108 Papanicolaou test, 137 Parachute reflex, 108 Parents’ Evaluation of Developmental

Status (PEDS), 99 Past medical history (PMH), 25–26,

218–219, 221 Patient-controlled analgesia, 232, 233 Patient counseling on risks of negative

health habits, 28 Patient identification section, of

prescription, 199 Patient portal, 187 Patient(s)

communication with, 183–187 education of, 55–56 media use by, 187–188 noncompliance with medical treatment,

179, 181–182 rights of, under HIPAA, 11–12

Pediatric preventive care visits age-specific physical examinations, 106,

107–108 anticipatory guidance, 100–102 body mass index, 98 components of, 94, 97–106 developmental screening, 98–99 growth screening, 94, 97–98 immunization status, 100 laboratory screening tests, 99 overview of, 93–94 risk factor identification, 102–106 sports preparticipation physical

examination, 106 PEDS (Parents’ Evaluation of

Developmental Status), 99 Percentiles, 97

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392 | Index

Perinatal and postpartum care documentation, 83–88

delivery note, 83–86 newborn history and physical

examination, 88 newborn physical examination, 87 postpartum note, 86–87

Perioperative orders, 229–234 Personal habits

review of, 26–27 risk factors associated with, 126

Pharmacological treatment, 55 Phenylketonuria (PKU), 99 PHI (protected health information), 11,

13, 186 Physical abuse, 102, 105 Physical examination

admission, 218–221 age-specific, 106, 107–108 comprehensive. See Comprehensive

history and physical examination description of, 29–31 hospitalization, 218–221 medical admission, 218–221 prenatal care documentation, 81–82 sports preparticipation, 106 surgical, 221–223

Placing and stepping reflex, 108 Plan of care

admission history and physical examination, 220

comprehensive history and physical examination, 32

surgical history and physical examination, 223

Plantar grasp reflex, 108 Postanesthesia care unit order, 229, 231 Postoperative progress note, 260, 264 Postoperative orders, 234 Postpartum note, 86–87 Practitioner, defined, 196 Preconception care, 137–138 Preexisting condition, 10 Prenatal care documentation, 80–83

demographic information, 80 health promotion and disease

prevention, 83 laboratory data and diagnostic tests, 82 maternal history, 80–81 nutrition, 83 physical examination, 81–82 psychosocial factors, 83 visits throughout pregnancy, 84

Pre-operative evaluation of older adults, 162–164

Pre-operative history, 289 Pre-operative orders, 229, 230 Prescribers

identification of, 199 safeguards for, 197, 199

Prescription form, 202 Prescription(s)

adverse drug events caused by, 203 drug abuse, 196 elements of, 199, 200 illicit use of, 196

statistics regarding, 195 Prescription writing

abbreviations used in, 203 authority for, 196–197 controlled medications, 201, 203, 205, 206 errors in, 195, 202–203, 228 noncontrolled medications, 199–201 prevalence of, 195

Preventive care visits adult, 153 components of, 126 definition of, 125 documentation of, 126–139 gender-specific screening, 136–139 health education and counseling, 139 immunization status, 139 older adult, 153 overview of, 125–126 pediatric. See Pediatric preventive care visits risk factor identification. See Risk factor

identification Primary care provider, 182 Primary code, 7 Primary prevention, 125 Prior medical records, 183 Privacy, under HIPAA

Privacy Rule, 10–13 violations and penalties associated with, 13

Problem list admission history and physical

examination, 220 comprehensive history and physical

examination, 32 outpatient charting and communication,

173–176 surgical history and physical

examination, 223 Procedure note, 272–273 Progress note, daily

content of, 257–260 description of, 257 medical admissions, 257–259 surgical admissions, 260, 261–263

Prostate-specific antigen (PSA) screening, 138

Protected health information (PHI), 11, 13, 186

Providers communication with patient, 183–187 DEA identifier number for, 197, 199 other, communication with, 182 prescription writing by. See Prescription

writing PSA (prostate-specific antigen) screening, 138 Psychiatric system, review of, 29 Psychosocial factors, prenatal care

documentation, 83

Q Quotations, 47–48

R Recommended Uniform Screening Panel

(RUSP), 99 Rectal examination, 30

Referral defined, 182 letter sample, 183

Referring provider, 182 Refill information section, of prescription,

200–201 Reflexes, 31, 108 Rehabilitation Act of 1973, 219 Religious beliefs, 27 Respiratory examination, 30 Respiratory system, review of, 28, 107 Review of systems (ROS)

admitting patient to the hospital, 219–220

comprehensive history and physical examination, 28–29

surgical history and physical examination, 223

Rheumatoid arthritis, 128 Rinne test, 161–162 Risk factor identification

alcohol consumption, 130–131 blood product transfusions, 134 body mass index, 128–129 description of, 126 diet, 126, 128 exercise, 126 family history, 135 intimate partner violence, 133–134 nutrition, 126, 128 occupational history, 134 oral health, 134 pediatric, 102–106 safety measures, 134 screening tests, 135–136 sexual history, 132–133 substance abuse, 131–132, 133 tobacco use, 129–130

Rooting reflex, 108 ROS. See Review of systems (ROS) RUSP (Recommended Uniform Screening

Panel), 99

S Safety measures, 134 Screening(s)

abdominal aortic aneurysm, 138 breast cancer, 137 cervical cancer, 137 colon cancer, 137 Denver Developmental Screening Test

II (DDST-II), 99 developmental, 98–99 diabetes mellitus, 137, 138 diagnostic, 126 Drug Abuse Screening Test, 131, 133 Early and Periodic Screening, Diagnosis,

and Treatment program (EPSDT), 93 FIST screening, 102, 104 gender-specific, 136–139 growth, 94, 97–98 hearing impairment screening, 159 hepatitis C, 137 HIV, 137 hypertension, 137

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Index | 393

indications for, 126 IPV screening and counseling, 137 laboratory tests, 126 lead exposure, 99 for men, 138–139 mental health screening, 160, 161 National Institute of Drug Abuse

Modified Alcohol, Smoking, and Substance Involvement Screening Test (NIDA ASSIST), 131

older adult medical conditions, 162 osteoporosis, 137 pediatric BMI, 94, 97–98 pediatric laboratory tests, 99 prostate-specific antigen (PSA), 138 recommended types of, 136–139 Recommended Uniform Screening

Panel (RUSP), 99 risk factor identification based on,

135–136 screening mammography, 126 sensory deficit screening, 159–160 sexually transmitted infections, 137, 138 tuberculosis, 137 USPSTF screening recommendations, 162 for women, 136–138 Youth at Risk Screening Questionnaire,

105 Secondary codes, 7 Secondary prevention, 125 Security, 13–14 Sensitive protected health information, 11 Sensory deficits in older adults, 159–160 Sensory examinations, 161–162 Sensory testing, 31 Sexual abuse, 102, 105 Sexual history, 132–133 Sexually transmitted infection (STI)

adult preventive care, 133 email confidentiality, 186 genitourinary review of systems, 28 prenatal care documentation, 81 prenatal test result documentation, 82 risk assessment, screening, and

counseling, 137, 138 Signa section, of prescription, 200 Signature section, of prescription, 201 Skin, review of, 107 Skin examination, 29 Sleep hygiene guide, 56 Smoking, 129–130 SOAP notes

Assessment portion of, 52–54, 257 description of, 45, 257 diagnostic test results, 50, 54

differential diagnoses, 52, 53 follow-up instructions, 56, 58 interventions done during the visit,

50–51 laboratory tests, 54 Objective information portion of,

48–51, 257 patient education, 55–56 Plan portion of, 54–58 procedure note, 272–273 Subjective information portion of,

45–48, 257 therapeutic modalities, 55

Social history in admission history, 219, 221, 223 in adolescents, 102 in adults, 26–27

Social media, 187–188 Social Security number, 179 Soft diet, 232 Special instruction orders, 229, 234 Spinal accessory nerve, 30 Sports preparticipation physical

examination, 106 Startle reflex, 108 STI. See Sexually transmitted infection (STI) Stroke, 135 Subscription section, of prescription, 200 Substance abuse, 131–132, 133 Sudden death, 106 Surgery

admissions, 260, 261–263 history and physical examination,

221–223 pre-operative evaluation of older adults,

162–164 Systems heading format, for documenting

objective information, 50

T T-ACE questionnaire, 131 Telemedicine, 186 Telemetry, 221 Telephone communications, 183–185 Tertiary prevention, 125 Testes, 107 Therapeutic modalities, 55 Throat examination, 30 Timed Up and Go test, 162 Tinetti Performance Oriented Mobility

Assessment tool, 162 Tobacco use, 129–130 Trigeminal nerve, 30 Trochlear nerve, 30

Trunk incurvation reflex, 108 Tuberculosis screening, 137 Type 2 diabetes, 97–98

U U.S. Preventive Services Task Force

(USPSTF) hearing impairment screening, 159 medical conditions, 162 risk factor identification based on

screening tests, 135–136

V Vaccinations See also immunizations

older adults, 162 refusal of, 100

Vagus nerve, 30 Vegetarians, 128 Vision testing, 160, 161 Vital signs

in admission history and physical examination, 220

admission orders, 227–228 monitoring, 258 objective information, 48 physical examination, 29 postoperative orders, 230

W Wandering, 293–294 Warnings section, of prescription, 201 Weber test, 161–162 Websites for medical education, 187 Well-child visits

components of, 94, 97–106 description of, 93

Well-man examination, 138–139 Well-woman examination, 136–137 WHO. See World Health Organization

(WHO) Women

screening for, 136–138 sports preparticipation physical

examination for, 106 World Health Organization (WHO)

growth standards, 94 health promotion, defined, 55 International Classification of Diseases

(ICD), 6

Y Youth at Risk Screening Questionnaire, 105

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