Progress Note

Progress Note

o   SUBJECTIVE

o   Use Chief Complaint section – should be chief complaint for today – not from H&P

o   4 components of OPQRST for chief complaint or new issues

§  Note exacerbating and relieving factors count as just 1

§  IF patient has no pain, or new symptom/problem, must include 4 things discussed with patient (these must be status of current issues (EG: Discussed improvements in breathing from heart failure) that are not ROS items

o   ROS with 2 systems with 2 components each

o   “Complete ROS reviewed and is negative except as noted”

o   “PMHx/PSHx/Fam Hx/Soc Hx reviewed”

o   DO NOT MINIMIZE – DO NOT write “stable overnight”, “No new complaints” etc…

o   VITAL SIGNS

o   MEDICATIONS

o   PE with 8 systems with 2 components each

o   Labs

o   Results – review all if new or not done on a prior note:

o   IF Tele: “I personally reviewed patient’s telemetry strips and they show {result}”

o   IF EKG: “I Personally reviewed patient’s EKG and it shows {result}”

o   IF CXR: “I personally reviewed patient’s CXR and it shows {result}, final read per radiologist

o   ASSESSMENTS: (At least 4 items)

# Each assessment (especially the top 4) should include

1)    An accurate billable assessment: EG: Acute HFpEF (not “CHF” or “dyspnea”)

2)    Then the status (improving, worsening, BUT NEVER stable): “Improving with diuresis”

3)    Intelligent Differentials with reasoning: “Causes include increased salt intake, noncompliance with medications” AND what you’ve done to mitigate / rule out these causes “We have extensively discussed medication and diet compliance”

4)    An ASSESSMENT (not raw data) of any pertinent finding that supports the assessment: EG: “Echo shows preserved EF 72% with grade 2 diastolic dysfunction.”

5)    DO NOT USE “Stable” – use “persistent” or “still requiring”

# Change order of assessments every day to reflect clinical course

# Write ‘case discussed with Dr. {name} and he/she said what” – this can be a consultant, ER doctor, ER PA, whoever. This can be assessment or plan depending on which is more appropriate.

# DO NOT put any labs, med doses or values that change daily – instead include assessments of these values “Anemia is worsening despite EGD with cautery on 5/12” In stead of “Hgb 6.6-7.1-8.1-6.4”

# Chronic conditions can be listed as Issue – condition, meds at home: EG: “HTN – well controlled on home lisinopril”

o   PLAN: (At least 4 items)

- Write what your plan is for (EG: “Restart Warfarin for Afib”)

- DO NOT use the word ‘continue’

- DO NOT state medication doses or sigs – just ‘atorvastatin’, “increased IV Lasix” (exception: warfarin and insulin)

- DO write antibiotics + Start date and expected stop if known

- DO write rout of administration for IV medications EG: “IV dilaudid”

- don’t “monitor” state what you’re “monitoring” EG: “BMP in AM.”

FEN: Fluids, Electrolytes, Nutrition

-       Do not cop out EG: PO, Check Daily, Reg. Instead: FEN: Fluids PO, Electrolytes within normal limits, Regular Diet

PROPHY: DVT prophylaxis

CODE:

DISPO: explain why patient needs continued inpatient stay EG: “pending cholecystectomy tomorrow” NOT “Inpatient due to high risk of decompensation…”

-       NEVER write “Patient needs 3 midnight stay for SNF placement” Or anything like that. Explain medical necessity instead EG: “Patient too weak and unsafe to go home per PT, placement pending.”