SOAP # 1 Daisy Day Date of Service: Patient Name: DOB ...
Transcript of SOAP # 1 Daisy Day Date of Service: Patient Name: DOB ...
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SOAP # 1 – Daisy Day Date of Service: 02/05/2021
Patient Name: Daisy Day
DOB: 09/18/2017
Chief Complaint - Other
HPI Debbie is a 4-year-old child Yesterday they went to dinner Running fevers and threw up Sister came in and said that her sisters' legs were kicking Has not had one in 2 years Fell asleep and then went to the store No more vomiting, diarrhea, runny nose or pain with urination
Past Medical History:
• History of urinary tract infections, Otitis Media, seizure from fever (05/15)
Family History:
• diabetes material grandmother
Social History:
• Lives with 2 sisters
• Parents – divorced, split custodial rights
• Does anyone who lives in the home smoke tobacco? No
Examination
• General Appearance: active, NAD • HEENT: Eyes: non-injected and no exudates. Ears: TM’s membranes pearly w/good landmarks.
Nose: no nasal discharge Tonsils: no erythema or exudate and not enlarged Oropharynx: moist mucosa and normal oropharynx
• Cardio: Heart sound: increased HR, regular rhythm • Lungs: clear to auscultation bilaterally • Abdomen: no abdominal tenderness, non-distended • Skin: warm, well perfused. No lesions, no rash
Assessment/Plan:
Daisy is a 4 year-old child with h/o febrile seizures who had sz activity this morning (unwitnessed by
parents), fever and vomiting. She is well appearing in office with supple neck. She also has h/o UTI.
Attempted to give urine sample but unable in office.
COVID testing performed
Call if worsening symptoms, neck stiffness, persistent vomiting or fevers, concerns
Fever - R50.9 Fever, unspecified - Instructed to give Children’s Tylenol 160/mg/5mL oral suspension
Electronically Signed: Debbie Johns, MD 2/06/21 at 3:44 pm
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SOAP # 2 – Robert Redman
Date of Service: 01/12/2021
Patient Name: Robert Redman
DOB: 07/15/1953
PROVIDER: Andrew Johnson, MD
CHIEF COMPLAINT: Acute Visit
Nursing documentation:
November 30, 2020 – Weight 159 lbs.
January 12, 2021 – Weight 129 lbs.
SpO2 on Room Air @ Rest: Unable to get readings on oximeters due to cyanosis, attempted twice
Patient has nocturnal O2 but sometimes used during the day.
Vital Signs: 97.5F
HISTORY:
No history of gout but flare of symptoms in feet, discussed results of arterial u/s which was normal for
upper extremities. Complains of some fatigue and thinks it is from waking constantly due to foot pain.
ROS: Negative fever or chills, headache, double vision or blurry vision, ear pain, throat pain, nasal
congestion, neck pain or stiffness, cough, chest pain, palpitations, shortness of breath, abdominal pain,
nausea, vomiting diarrhea, weight gain, weight loss, dysuria, urgency, frequency, hematuria, difficult
speaking difficult swallowing, swollen or tender lymph nodes, bruising, hematochesia, hematemesis,
rash extremity pain or swelling weakness, numbness.
PAST MEDICAL, FAMILY AND SOCIAL HISTORY:
Past Medical History:
• Parkinsonism
• Persistent tremor
• Elevated PSA
• Hypoxemia
• COPD
• Hypertension
• History of tobacco
• Sensorineural hearing loss, bilaterally
• Insomnia
• Hyperlipidemia
Family History:
Social History:
• Tobacco – quit in 2000
Allergies – Patient denies any allergies to medications
Medications have been reviewed with the patient to ensure that all active medications are listed and
have determined how the patient is taking the medications and updated as necessary.
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EXAMINATION:
General: Alert and oriented x 3 – NAD
Eyes: PERRL EOMI
Neck: Supple, NT negative adenopathy
CV: Regular rate, rhythm no murmur
Respiratory: Clear to auscultation bilaterally
Abdomen – soft non tender positive bowel sounds
Back: negative for CVA tenderness
Extremities: negative cyanosis, clubbing or edema
Neuro: grossly normal, negative cerebellar signs
Skin: negative rash, warm and dry
• Diet exercise and all normal and abnormal test results have been reviewed with the person –
no questions
• Colorectal Cancer Screen: patient declines screening
ASSESSMENT:
Diagnosis/Plan:
• Parkinson’s – G20
• Probably gout – M10.9
PLAN:
Diclofenac cream for flares, check uric acid level, rtc annual
Approximately 35 minutes spent with patient answering questions.
Electronically Signed: Andrew Johnson, MD 01/12/21 13:45
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SOAP #3 – Robert Redman (Hospital) Patient Name: Robert Redman
DOB: 07/15/53
DOS: 01/14/21
Service: Donald Pace, MD Hospitalist Admit
Chief Complaint: Generalize Weakness
HPI:
Robert is a 66 year old male with a history of HTN, COPD, and Parkinson’s who presents for
approximately 2-3 days of progressive and extreme weakness, fatigue, uncontrollable chills,
hypotension, nausea and vomiting. Patient’s wife and son are at bedside and help provide history. Wife
reports over the last couple of days the patient has become increasingly fatigued and weak. EMS was
called and patient was found to be hypotensive with systolic blood pressures in the 70s. He states the
weakness is generalized and not located to any specific region of the body. The patient has a history of
double pneumonia in the past but this event there were no indications or symptoms of pneumonia which
is unlike his previous event when he was diagnosed with double pneumonia. Prior to presentation to the
ED the patient additionally reports lightheadedness and one episode of emesis. He also endorses some
mild chest tightness, but states the tightness feels similar to COPD symptoms and may be secondary to
missing a nebulizer treatment due to fatigue. He denies any associated abdominal pain, dysuria or
burning with urination.
Of note, the patient endorses an unintentional weight loss of approximately 30 pounds in the last 2
months. He states this is secondary to his decreased appetite, and his wife reports it is “difficult to get
him to eat anything”. No significant changes or severity with his Parkinson’s. Will admit to ICU for
treatment of septic shock.
Past Medical History:
• COPD
• Hypertension
• Parkinson Disease
Past Surgical History:
• Dental surgery – removal of all teeth
Family History:
• Father died at 67 due to Alzheimer’s, pneumonia, and alcoholism
• Mother died at 72 due to AAA - Abdominal Aortic Aneurysm
• Brother died at 62 of brain cancer
Social History:
• Marital Status: Married – Jayme
• Number of Children – 5
• Smoking: Former cigarette smoker – quit 2000
• Does not drink alcohol
Allergies – patient allergic to penicillin
Review of Systems:
• Constitutional: positive for malaise/fatigue. Negative for chills/fever
• Respiratory: negative for cough
• Cardiovascular: negative for chest pain
• Gastrointestinal: positive for vomiting, negative for abdominal pain
• Musculoskeletal: negative for myalgias
• Skin: negative for itching/rash
• Neurological: positive for tremors
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• Psychiatric/Behavioral: Negative for depression. The patient is not nervous/anxious.
• All other systems reviewed and are negative
Examination:
Vitals: BP: 86/55 upon arrival SpO2: 89% Pulse: 95 BMI 18.9
General: Well appearing, A&O x 3
Eyes and ENT: PERRLA, EOMI
Respiratory: Low-pitched wheezing (rhonchi) indicated in left lung. Per radiology - Left midlung
consolidation is most suggestive of a pneumonia
CV: Regular rate and rhythm
GI: Soft, nontender, nondistended, normoactive bowel sounds
Skin: warm and dry, no rashes, no ulcers
Musculoskeletal: no joint effusions, deformities, no clubbing, no cyanosis
Neuro: follows commands, CN’s II-XII grossly intact
Psychiatric: Normal mood and affect, indicates he feels like he is in a fog and not sure of everything that
is going on
Results/Verification of Data Review:
• POCT Lactate
• Hepatic Function Panel
• CBC with Auto Differential
• Lipase
• Smear review
• CMP
• Blood Culture
• POCT Troponin
• POCT Lactate
Radiology – Xr Chest Single View Result date: 01/14/21
Examination: XR CHEST SINGLE VIEW Comparison: 1/18/19 History: Weakness Findings: Chronic
pulmonary hyperexpansion. New left midlung-ill defined consolidation. No pneumothorax, edema or
effusion. Cardiac and hilar contour size is within normal limits. Osseous structures are intact.
Impression: Left midlung consolidation is most suggestive of a pneumonia. Radiographic follow-up 4-6
weeks to document resolution and exclude the presence of a pulmonary nodule is recommended. Report
E-signed by: Daniel Donaldson, MD 1/14/21 9PM
Assessment and Plan
Septic Shock
• Hypotension
• Leukocytosis
• EKG show atrial fibrillation with ventricular rate of 89
• Troponin 0 0.00
• WBS 23
• Lactate 3.12 will trend
• Begin levo fed, goal to keep mean arterial pressure greater than 60 mmHg
• Admit to ICU
• Continue lactated Ringer’s at 125 cc/h
• Continue Azithromycin and Cefepime
• Follow blood and urine cultures
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• Check urinalysis
• Check serial lactates
• Sepsis protocol
• Check Procalcitonin
• Check CT chest abdomen pelvis
• Check Lipase
• Recheck AM BMP and CBC
Acute kidney injury
• Cr 3.03.. baseline 1.3
• Hold Lisinopril
• Avoid nephrotoxic meds
• Hold topical diclofenac
• Recheck BMP
Chest Pain
• Patient has left-sides chest and feels like it is related to COPD
• Denies exertional anginal symptom
• Start ASA 81 mg
• Troponin 0.0
• Check serial troponins
• Check echocardiogram
Bilateral Pneumonia
• Chest x-ray 7/1 left lung consolidation is most suggestive of a pneumonia.
• Recheck chest x-ray in am.
COPD without acute exacerbation
• Oxygen, duo nebs, RT protocol, pulmonary toilet
• Continue home albuterol MDI
Parkinson’s disease
• Continue home carbidopa levodopa
• Hold Inderal
Hypertension
• Hold home HCTZ, lisinopril and Inderal given hypotension
I spent 40 minutes in Critical Care with this patient due to systems failing including septic shock and
kidney failure. This is excluding procedures and not overlapping with other providers.
Advanced Care Plan – Full code
By signing my name below, I, Stacie Schmitt, attest that this documentation has been prepared under
the direction in the presence of Donald Pace, MD Electronically signed: Stacie Schmitt, Scribe 01/14/21
9:45 PM
I, Dr. Donald Pace, personally performed the services described in this documentation. All medical record
entries made by the scribe were at my direction and in my presence. I have reviewed the chart and
discharge instructions (if applicable) and agree that the record reflects my personal performance and is
accurate and complete. Pace, Donald, MD 01/14/21 @ 11:06 PM
Electronically signed by Donald Pace, MD 01/14/21 at 11:06 PM
Presentation by :
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, CMCS
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Dissecting Documentation
AGENDA
• Have the following notes available for dissection
• SOAP # 1 – Daisy Day
• SOAP # 3 – Robert Redman (Office Encounter)
• SOAP # 3 – Robert Redman (Hospital Admit)
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S O A P
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S
O
A
P
Subjective or History Part of Note Includes the History of Present Illness, Review of Systems, Past Medical, Family and Social History
Observation is the hands-on examination of the
patient by the provider
AssessmentThe providers diagnosis for Medical Decision Making
(MDM)
PlanPlan on current and future treatment of patient and is
part of Medical Decision Making (MDM)
REVIEW NOT AUDIT
• How to review the documentation to look for errors.
• This is not an audit to determine the level.
• Purpose is the verify documentation and was it properly billed on the CMS-1500.
• Exercises help understand what is contained in a SOAP note.
• We are not auditing to determine level, only reviewing documentation
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WHAT ARE WE REVIEWING?
• Patient correct name?
• Date of Service
• Physician signature identified and is the same provider's name on the
CMS1500
• Electronic signature and sign off date by the physician
• Billed as Incident-to?
• Identified on CMS-1500, documentation, supervising physician
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WHAT ARE WE REVIEWING?
• Chief Complaint
• History, Exam, Plan and Assessment documented
• Not audited, listed
• Diagnosis
• Diagnosis addressed
• Listed on CMS-1500
• Time documentation
• Is the encounter based on time and is it supported with detail
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WHAT ARE WE REVIEWING?
• Documentation clearly paints the picture of the patient’s illness, injury or condition
• Conflicting information
• Patterns/Trends
• Padding of documentation
• Cloned notes
• Copy/Paste
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DISSECTING NOTES
• Now we are going to go through some notes
• You will need the following notes to help answer questions
• These are actual notes I have encountered
• Daisy Day - SOAP #1
• Robert Redman (Office Visit) – SOAP #2
• Robert Redman (Hospital Admit) – SOAP #3
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VERIFING THE DOCUMENTATION
• Patient Daisy Day – SOAP #1
• Verify:
• Patient name
• Date of service
• Physician signature
• Sign off date
• Billed as Incident-to
• Chief Complaint
• History, Exam, Plan and Assessment documented
• Diagnosis billed and listed on CMS-1500
• Time documentation
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Daisy Day – SOAP #1
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Date of Service: 02/05/2021Patient Name: Daisy Day
DOB: 09/18/2017
Electronically Signed: Debbie Johns, MD 2/06/21 at 3:44 pm
CHIEF COMPLAINT, HISTORYChief Complaint - Other
HPI • Debbie is a 4-year-old child• Yesterday they went to dinner • Running fevers and threw up • Sister came in and said that her sisters' legs were kicking • Has not had one in 2 years• Fell asleep and then went to the store• No more vomiting, diarrhea, runny nose or pain with urination
Past Medical History: History of urinary tract infections, Otitis Media, seizure from fever (05/15)Family History: diabetes material grandmotherSocial History: Lives with 2 sisters, Parents – divorced, split custodial rights, Does anyone who lives in the home smoke tobacco? No
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EXAMINATION, ASSESSMENT, PLAN
Examination•General Appearance: active, NAD•HEENT: Eyes: non-injected and no exudates. Ears: TM’s membranes pearly w/good landmarks. Nose: no nasal discharge Tonsils: no erythema or exudate and not enlarged Oropharynx: moist mucosa and normal oropharynx•Cardio: Heart sound: increased HR, regular rhythm•Lungs: clear to auscultation bilaterally •Abdomen: no abdominal tenderness, non-distended•Skin: warm, well perfused. No lesions, no rash
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ASSESSMENT AND PLAN
R50.9
Assessment/Plan:
• Daisy is a 4-year-old child with h/o febrile seizures who had sz activity this morning
(unwitnessed by parents), fever and vomiting. She is well appearing in office with
supple neck. She also has h/o UTI.• Attempted to give urine sample but unable in office.
• COVID testing performed
• Call if worsening symptoms, neck stiffness, persistent vomiting or fevers, concerns
Fever - R50.9 Fever, unspecified - Instructed to give Children’s Tylenol 160/mg/5mL oral
suspension
Is diagnosis noted correctly on CMS-1500?
VERIFING THE DOCUMENTATION
• Patient Robert Redman – SOAP #2
• Verify:
• Patient name
• Date of service
• Physician signature
• Sign off date
• Billed as Incident-to
• Chief Complaint
• History, Exam, Plan and Assessment documented
• Diagnosis billed and listed on CMS-1500
• Time documentation
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Robert Redman – SOAP #2
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Date of Service: 01/12/2021
Patient Name: Robert Redman
DOB: 07/15/1953
PROVIDER: Andrew Johnson, MD
Approximately 35 minutes spent with patient answering questions.
Electronically Signed: Andrew Johnson, MD 01/12/21 13:45
CHIEF COMPLAINT, HISTORYCHIEF COMPLAINT: Acute Visit
Nursing documentation:
• November 30, 2020 – Weight 159 lbs January 12, 2021 – Weight 129 lbs.
• SpO2 on Room Air @ Rest: Unable to get readings on oximeters due to cyanosis, attempted twice
• Patient has nocturnal O2 but sometimes used during the day. Vital Signs: 97.5F
HISTORY:
No history of gout but flare of symptoms in feet, discussed results of arterial u/s which was normal for
upper extremities. Complains of some fatigue and thinks it is from waking constantly due to foot pain.
ROS: Negative fever or chills, headache, double vision or blurry vision, ear pain, throat pain, nasal
congestion, neck pain or stiffness, cough, chest pain, palpitations, shortness of breath, abdominal pain,
nausea, vomiting/diarrhea, weight gain, weight loss, dysuria, urgency, frequency, hematuria, difficult
speaking difficult swallowing, swollen or tender lymph nodes, bruising, hematochesia, hematemesis, rash
extremity pain or swelling weakness, numbness.
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PAST MEDICAL, FAMILY, SOCIAL HISTORY
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Past Medical History:
Parkinsonism, Persistent tremor, Elevated PSA, Hypoxemia, COPD,
Hypertension, History of tobacco, Sensorineural hearing loss bilaterally,
Insomnia, Hyperlipidemia
Family History:
Social History: tobacco – quit in 2000
Allergies – Patient denies any allergies to medications
EXAMINATION
EXAMINATION: • General: Alert and oriented x 3 – NAD • Eyes: PERRL EOMI • Neck: Supple, NT negative adenopathy • CV: Regular rate, rhythm no murmur • Respiratory: Clear to auscultation bilaterally • Abdomen – soft non tender positive bowel sounds • Back: negative for CVA tenderness• Extremities: negative cyanosis, clubbing or edema • Neuro: grossly normal, negative cerebellar signs • Skin: negative rash, warm and dry
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ASSESSMENT AND PLAN
G20
• Diet exercise and all normal and abnormal test results have been reviewed with the person – no questions
• Colorectal Cancer Screen: patient declines screening
ASSESSMENT:
Diagnosis/Plan:
• Parkinson’s
• Probably gout
PLAN:
Diclofenac cream for flares, check uric acid level, rtc annual
Approximately 35 minutes spent with patient answering questions.
Is diagnosis noted correctly on CMS-1500?
M10.9
Robert Redman – SOAP #3 (Hospital)
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Date of Service: 01/14/2021
Patient Name: Robert Redman
DOB: 07/15/1953
PROVIDER: Donald Pace, MD
Electronically Signed: Donald Pace, MD 01/14/21 11:06 PM
CHIEF COMPLAINT, HISTORYChief Complaint: Generalize Weakness
HPI: Robert is a 66-year-old male with a history of HTN, COPD, and Parkinson’s who presents for approximately 2-3 days of progressive and extreme weakness, fatigue, uncontrollable chills, hypotension, nausea and vomiting. Patient’s wife and son are at bedside and help provide history. Wife reports over the last couple of days the patient has become increasingly fatigued and weak. EMS was called and patient was found to be hypotensive with systolic blood pressures in the 70s. He states the weakness is generalized and not located to any specific region of the body. The patient has a history of double pneumonia in the past but this event there were no indications or symptoms of pneumonia which is unlike his previous event when he was diagnosed with double pneumonia. Prior to presentation to the ED the patient additionally reports lightheadedness and one episode of emesis. He also endorses some mild chest tightness, but states the tightness feels similar to COPD symptoms and may be secondary to missing a nebulizer treatment due to fatigue. He denies any associated abdominal pain, dysuria or burning with urination. • Of note, the patient endorses an unintentional weight loss of approximately 30 pounds in the last 2 months. He states this is secondary to his decreased appetite, and his wife reports it is “difficult to get him to eat anything”. No significant changes or severity with his Parkinson’s. Will admit to ICU for treatment of septic shock.
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ROS
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Review of Systems:
• Constitutional: positive for malaise/fatigue. Negative for chills/fever
• Respiratory: negative for cough
• Cardiovascular: negative for chest pain
• Gastrointestinal: positive for vomiting, negative for abdominal pain
• Musculoskeletal: negative for myalgias
• Skin: negative for itching/rash
• Neurological: positive for tremors
• Psychiatric/Behavioral: Negative for depression. The patient is not
nervous/anxious.
• All other systems reviewed and are negative
PAST MEDICAL, FAMILY, SOCIAL HISTORY
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Past Medical History:
• COPD
• Hypertension
• Parkinson Disease
Past Surgical History:
• Dental surgery – removal of all teeth
Family History:
• Father died at 67 due to Alzheimer’s, pneumonia, and alcoholism
• Mother died at 72 due to AAA - Abdominal Aortic Aneurysm
• Brother died at 62 of brain cancer
Social History:
• Marital Status: Married – Jayme
• Number of Children – 5
• Smoking: Former cigarette smoker – quit 2000
• Does not drink alcohol
Allergies – patient allergic to penicillin
EXAMINATIONExamination: • Vitals: BP: 86/55 upon arrival SpO2: 89% Pulse: 95 BMI 18.9 • General: Well appearing, A&O x 3• Eyes and ENT: PERRLA, EOMI • Respiratory: Clear to auscultation bilaterally. • CV: Regular rate and rhythm• GI: Soft, nontender, nondistended, normoactive bowel sounds• Skin: warm and dry, no rashes, no ulcers• Musculoskeletal: no joint effusions, deformities, no clubbing, no cyanosis• Neuro: follows commands, CN’s II-XII grossly intact • Psychiatric: Normal mood and affect, indicates he feels like he is in a fog and not
sure of everything that is going on
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TESTING
Results/Verification of Data Review:
• POCT Lactate, Hepatic Function Panel, CBC with Auto Differential, Lipase, Smear
review, CMP, Blood Culture, POCT Troponin, POCT Lactate
Radiology – Xr Chest Single View Result date: 01/14/21
• Examination: XR CHEST SINGLE VIEW Comparison: 1/18/19 History: Weakness
Findings: Chronic pulmonary hyperexpansion. New left midlung-ill defined
consolidation. No pneumothorax, edema or effusion. Cardiac and hilar contour
size is within normal limits. Osseous structures are intact. Impression: Left midlung
consolidation is most suggestive of a pneumonia. Radiographic follow-up 4-6
weeks to document resolution and exclude the presence of a pulmonary nodule is
recommended. Report E-signed by: Daniel Donaldson, MD 1/14/21 9PM
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ASSESSMENT AND PLANAssessment and Plan
Septic Shock
- Hypotension, Leukocytosis, EKG show atrial fibrillation with ventricular rate of 89,
Troponin 0 0.00, WBS 23, Lactate 3.12 will trend, Begin levo fed, goal to keep mean
arterial pressure greater than 60 mmHg
- Admit to ICU, Continue lactated Ringer’s at 125 cc/h, Continue Azithromycin and
Cefepime, Follow blood and urine cultures, Check urinalysis, Check serial lactates, Sepsis
protocol, Check Procalcitonin
- Check CT chest abdomen pelvis, Check Lipase, Recheck AM BMP and CBC
Acute kidney injury
- Cr 3.03.. baseline 1.3, Hold Lisinopril, Avoid nephrotoxic meds, Hold topical diclofenac,
Recheck BMP
ASSESSMENT AND PLANChest Pain
- Patient has left-sides chest and feels like it is related to COPD. Denies exertional anginal
symptom
- Start ASA 81 mg, Troponin 0.0, Check serial troponins, Check echocardiogram
Bilateral Pneumonia
- Chest x-ray 7/1 left lung consolidation is most suggestive of a pneumonia. Recheck
chest x-ray in am. COPD without acute exacerbation. Oxygen, duo nebs, RT protocol,
pulmonary toilet. Continue home albuterol MDI
Parkinson’s disease
- Continue home carbidopa levodopa, Hold Inderal
Hypertension
- Hold home HCTZ, lisinopril and Inderal given hypotension
PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER• Time documentation
• Office minimal questions asked of the patient – he documented 30 minutes answering questions
• Hospital – 40 minutes for critical care• Allergies to medication
• Office - No allergies documented and patient denies • Hospital - patient is allergic to penicillin
• Weight Loss • Office - did not address the 25-30 lb• Hospital - unintentional weight loss noted
• Review of Systems (ROS) Cyanosis/Shortness of breath• Office documented no cyanosis – nurse documented cyanosis and
could not get a pulse ox and No shortness of breath – patient came into office with portable O2
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PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER
• Examination
• Office - Respiratory: Clear to auscultation bilaterally
• Hospital - wheezing and pneumonia detected
• Office - Extremities: negative cyanosis (but is positive per nurse)
• Diagnosis
• Office Visit – Parkinsons, possible gout
• Hospital – pneumonia, septic shock
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PROBLEMS – OFFICE vs HOSPITAL ENCOUNTER
• Office Visit
• Diagnosis of Parkinsons
• Carbidopa prescribed 4 years ago
• Hospital• Per Neurologist - does not have Parkinson but has essential tremors
• Carbidopa caused kidney damage
• Wife was witness to providers office encounter
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DOCUMENTATION ERRORS
• You can see many times the documentation is not perfect
• Provider's signature indicates all the information is true and accurate.
• MUST read their notes before signing
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FACTS PUBLISHED IN REGARD TO EMR
• Journal of American Medical Association, New England Journal of Medicine
• Medication Errors
• Copy/paste or cloned notes
• Dependence on spell check
• Templates
• Speech recognition
• Drop down menu with limited choices
• Poor design
• Increased fraud/abuse/Compromise healthcare of patients
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COPY AND PASTE
• Is it permitted???
• Do you check previous encounter for copy/paste?
• Can lead to errors such as:
• Symptoms
• Medications
• Histories
• Multitude of errors
• Authentication of author
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TEMPLATES
• Templates
• Conflicting information
• Not relevant to age, gender
• End Result – more risk to providers
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EXAMPLE OF INCORRET TEMPLATE
• 9-year-old seen for burn with urination diagnosed with acute cystitis
• Plan: RX meds as directed. Instructed patient of safe use of meds, purpose, dosage, importance of finishing prescribed medications and possible toxic affects. Increase PO fluids, limit caffeine. Wipe from front to back, void frequently and after sexual intercourse. Patient verbalized understanding
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PADDING OF EXAM OR CLONING
• Padding the documentation is adding more information than is required.
• Example:
• Ears bilateral TM’s pearly gray with good light reflex, EAC’s are clear, external ears intact bilaterally and nontender. No mastoid tenderness, no pain on manipulation, no gross hearing loss noted. Nose normal nasal mucosa and turbinate's bilaterally, external exam of nose finds no abnormalities. Oral pharynx no inflammation, lips, teeth and gums intact. PND clear with no sinus tenderness on palpation.
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SPEECH RECOGNITION
• Homophone • A word that is pronounced the same as another word but
differs in meaning
• Examples:• Flour or flower• accept — except• appose - oppose • Dialects pick up words differently or if not said clearly
• Pancreas “Pan Grease”
• Doctors must review before signing off
• Can change the medical record and patient condition
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Homophone Errors
• The patient is 23-year-old female who presents with headache and bitten tongue. Per parents the patient has a history of grandma seizures.
• Chief Complaint – “bazaar behavior”
• 89-year-old female with history of remote middle cerebral ornery smoke ( cerebral coronary stroke)
• Walking Leonia instead of Walking Pneumonia
• "The patient has had a hard time breeding" (breathing).
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Humorous Documentation Errors
• Indication for flex sig – “blood when whipping himself” (wiping)
• Reason for leaving AMA – “pt wants to live” (leave)
• “He is allergic to wives.” (hives)
• Asking about DNR status – “I want my wife to receive artificial insemination”
• Between you and me, we ought to be able to get this lady pregnant.
• The lab test indicated abnormal lover function (liver function)
• Physician asked the patient if he smoked, Doctor documented, “like Bill Clinton, does not inhale”.
• "Testicles are mildly prominent." (It was a brain MRI)
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Just Darn Funny
• This 56-year-old patient brought into ED via ambulance with diabetic ketoacidosis. Wife states he has been complaining of nausea, vomiting and abdominal pain. He is Type I diabetic and is not under control with his diet or insulin regimen…………… Examination - Upon exam “I found a moon pie hidden in his underwear".
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PHYSICIANS NEED OUR HELP
• Physician need to document their thought processes
• Not taught in medical school
• Educate on proper documentation
• Teaching documentation, not coding
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Remind Your Physicians
Just because you got paid for it
doesn’t mean you will get to keep it,
it all depends on
YOUR DOCUMENTATION
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