How to write proper notes

2. Outline
 The Patient Chart
 Admission Note (History and Physical)
 Progress Notes
 Discharge Notes
 Operative Notes
 Pre and post-operative
 Procedure notes
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3. The Patient Chart
 Chart is located at the patient bedside,
electronically or at nursing station
 Essential components of the chart
 Admission notes, physicians Orders, administered
medications, vitals, progress notes, laboratory and
radiographic examinations and discharge summary

4. The Patient Chart
 Important medical and legal document
 Need to write legibly and sign your notes !!
 Everything you write must be co-signed by and
attending physician or by your senior resident !
 Always date, time and sign your notes !

6. The History and Physical
(H+P)
 Initial note for a patient admitted to the hospital
 Summarizes:
 Why the patient came to the hospital
 Medical history prior to this admission
 Initial physical exam to include initial labs/studies
 Gives the physician the opportunity to formulate a
differential diagnosis and treatment plan

7. The History + Physical (H+P)
Tips
 Always welcome the patient – ensure comfort
and privacy
 Know the patient’s name
 Introduce and identify yourself
 Set the agenda for the questioning

8. H+P Components
 Chief complaint
 History of Present
Illness
 Past Medical History
 Past Surgical History
 Allergies
 Medications
 Social History
 Family History
 Review of Systems
 Physical Exam
 Labs/Studies
 Assessment and Plan

9. Chief Complaint (CC)
 This is why the patient is in the Emergency
Room or in the office seeing you
 “This is in the patients own words”
 Examples:
 Shortness of breath
 Chest pain
 Nausea and Vomiting

10. History of Present Illness
(HPI)
 Detailed reason why patient is here
 Use the OPQRSTA approach to cover information
 Begin by listing all the relevant major medical
problems in first sentence
 Mr. Morris with history of hypertension, diabetes,
obstructive sleep apnea and osteoarthritis presented to
the hospital with ……

11. OPQRSTA Approach
 Onset:
 When did the CC occur
 Prior occurrences
 Progression
 Is it getting worse or
better?
 What makes it better or
worse
 Quality
 Is there pain, and if so
how would you
describe it?
 Radiation of
Symptoms
 Scale
 On scale of 1-10, how
bad are the symptoms
 Timing
 When do they occur?
 Associated symptoms
 Any other symptoms
not already covered

12. HPI Continued
 Include in this section a brief synopsis of what
was done in the ER or at an outside hospital
Example: 50 year old male with hypertension, diabetes, obstructive
sleep apnea and osteoarthritis presented to the hospital complaining of
fevers, chills and a cough for the past week. The cough started
approximately one week ago, was productive in nature, and had an
occasional blood tinge to it. The patient says that the fever and chills
began two days ago and has prevented him from sleeping at night.
Incidentally, the patient’s brother, who was visiting from Herat, was
recently ill with similar symptoms.

13. Past Medical and Surgical
History
 Major disease(adult and childhood) with brief discussion of
duration and treatment
 Ex: Hypertension x 10 years well controlled on medications,
s/p stroke in 1991 with residual left sided weakness
 Hospitalizations (Reason for admissions, when and where?)
 Surgical procedures with dates (Indications)
 Example: Open Cholecystectomy at age 46
 Immunizations

14. Other Components
 Medications:
 Dosage and duration
 Does patient take the
medications?
 Over the counter and herbal
medications
 Allergies:
 Record allergies and reactions
to medications, foods and latex
 No known drug allergies
 Social history:
 Occupation
 Tobacco, alcohol or illicit
drug use
 Marital and children status
 Family History:
 Include inherited diseases
 Ex: + Diabetes in mother and
sister

15. Review of Systems (ROS)
 Series of questions based on organ system:
 General/Constitutional
 Skin/Breast
 Eyes/Ears/Nose/Mouth/Throat
 Cardiovascular
 Respiratory
 Gastrointestinal
 Musculoskeletal
 Neurologic/Psychiatric
It is acceptable to write: ROS
as per HPI, otherwise
negative

16. Physical Examination
 General (Always include vital signs)
 HEENT (Head, eyes, ears, nose, throat)
 Heart
 Lungs
 Abdomen
 Extremities
 Skin
 Neurology
You must do a Physical
Examination !!!
Need to develop a systematic
approach for doing the
physical examination !

17. Labs and Radiographic
Studies
 Admission labs and important studies
 Example:
 Complete blood count
 Chemistry panel
 Cardiac enzymes
 EKG
 Chest X-ray

18. Assessment and Plan
 Assessment of the patient:
 This is what you think is wrong with the patient
 Start with a short summary of 3-4 sentences
maximum
 Follow by listing each active problem numerically
with most important first

19. Assessment and Plan
 Assessment of the patient:
 Each problem you list requires an in depth assessment
which includes a differential diagnosis
 Support your thoughts with elements of the patient’s
history, physical, lab results
 Plan:
 Conclude with a detailed treatment plan
 Sign your note with resident year and phone number

20. Example
Plan: The differential diagnosis includes bacterial pneumonia, tuberculosis, viral
pneumonia, or less likely pulmonary sarcoid.
1. Pulmonary Infection:
- Obtain blood cultures x 3
- Obtain sputum cultures and smear x 3
- Start appropriate antibiotics for community acquired pneumonia
- Initiate primary tuberculosis treatment
- Admit to hospital with appropriate isolation precautions: respiratory and droplet precautions
2. Hypertension:
- Continue outpatient medications
3. Diabetes:
- Continue outpatient diabetic medications
- Institute an insulin sliding scale
Assessment: The patient is a 50 year old male with hypertension, diabetes, and
obstructive sleep apnea who presents to the hospital with a respiratory infection.

22. Progress (SOAP) Notes
 Every inpatient should have a daily progress note
in the chart
 This note allows you to:
 Communicate your thoughts about a patient’s condition
 Your treatment plan
 And any progress that has been made over the past 24
hours

23. S= Subjective
 Summarizes how the patient feels
 Includes pertinent events that occurred
overnight
 Look through nursing notes or ask the nurse
about how the patient did overnight

24. O=Objective
 Objective information including:
 Vital signs
○ Temperature, blood pressure, heart rate, respiratory rate,
oxygen saturation and pain scale
○ I/O (“Ins and Outs”)
 Pertinent physical exam findings
 More recent labs and diagnostic test results
 Current inpatient medications (include # of days on the
medication. For example, Gentamicin (7/14)

25. A= Assessment
 1-2 sentence summary of the prior two
sections which includes:
 Patient’s age, hospital day (if surgical patient include
post-op day), and disease process
 For example:
○ 50 year old male admitted with heart failure ….
○ 50 year old male post-op day # 3 status post
appendectomy ….

26. P= Plan
 This section includes:
 What you plan to accomplish over the next 24 hours
including medications, procedures, consults, or
discharges
 Again, always sign your notes and provide a contact
phone number

27. www.nexthospital.com

28. Discharge Summary
 Provides the patient and their outpatient
physicians with:
 Brief summary of the patient’s presentation to
the hospital
 The hospital course
 And any further treatment recommendations

29. Discharge Summary
 Important Components of a Discharge Summary
(see attached example):
 List the number one problem for the patient’s admission
 List important admission labs, vitals, signs + symptoms of
the patient
 Diagnostic work done during the patient’s admission
○ You can write in the discharge summary if there is any
work-up that is still pending at discharge
 Need to write down who the patient is to follow-up with …

30. www.heart-valve-surgery.com

31. Pre-Operative Note
 These notes are written on all surgical patients
 This is essentially a checklist to confirm all the
required pre-op information has been collected
and patient is ready for surgery
 This should be completed in the progress note
section prior to surgery

32. Pre-Operative Note Format
 Date and time
 Pre-op diagnosis: Appendicitis
 Procedure: Open
Appendectomy
 Pre-op Orders: Nothing Per Oral
(NPO)
 Labs: CBC, PT/PTT (record
results prior to the procedure)
 CXR: No active disease (note the
findings)
 EKG: Normal sinus rhythm (note any
abnormalities)
 Blood: Typed and crossed for 2 units
of O+
 Consent: Singed on chart
 Anesthesia: To see patient, or
patient seen, note on chart

33. Operative Note
 Pre-op Diagnosis: Appendicitis
 Post-Op Diagnosis: Appendicitis
 Procedure: Appendectomy (what was done?)
 Surgeons: Attending, resident and students
who scrubbed in on the procedure
 Findings: acutely inflamed appendix

34. Operative Note
 Anesthesia: general with endotracheal tube,
spinal, local, etc
 Fluids: amount and type (electrolytes, blood); also
record the urine output
 Estimated blood loss (EBL): amount in cc
 Drains: List all in the patient after the procedure
 Number, type and location

35. Operative Note
 Hardware: Relevant usually for orthopedics
 Specimens: Type of specimen sent to pathology
 Complications: List any complications
 Needle and sponge count: correct x 2
 Disposition: Stable, extubated, transferred to
recovery room

36. Post-Operative Notes
 Post-op checks are progress notes are usually
written 4-8 hrs after completion of case
 Documents the patient’s immediate post-op
condition and progress
 Use a modified SOAP note

37. Post-Operative Notes
 Status post (s/p): Procedure and indication
 S: Subjective
 Patient complaints or comments
 CHECK consciousness (alert, oriented, drowsy),
ambulating
 Taking oral medications
 Pain control

38. Post-Operative Note
 O= Objective
 Vitals: BP, HR, Respirations, Temp, O2 sat
 INS/OUTS: IV fluid, PO intake, drains/tubes
 Exam: Physical findings
○ Incisions/dressings -- clean, dry and intact (CDI)
○ Neurovascular status
 Meds: Routine or new medications (Antibiotics, DVT
prophylaxis)
 Labs: Results of labs since surgery

39. Post-Operative Note
 A/P: Assessment and Plan
 Patient is stable/unstable/critical status post
procedure
 Include problems and how you plan to address them
 Plans for diet, ambulation, dressing changes, fluid
management, foley, drains, pain management and
etc.
 Don’t forget to sign your name, date and provide a
phone number

40. Procedure Note
 After performing a procedure:
 It is imperative that you document procedures
performed on patients in the patient’s chart
 This allows other physicians to know what
occurred and can act if a complication should
arise later in the day

41. Procedure Note Format
 Procedure: What procedure did you do?
 Permit:
 Document that you explained and patient
understands the procedure
 Discussed alternatives, risks, and benefits of the
procedure to the patient
○ Risks: Bleeding, infection, reaction to anesthesia,
general injury, etc)

42. Procedure Note Format
 Indications: Why did you do the procedure?
 Physician (s): Who performed the
procedure?
 Description: How did you do the procedure?
 Where did you do the procedure?
 What anesthetic did you use?

43. Procedure Note Format
 Complications: Did anything go wrong with the
procedure, bleeding, pneumothorax, infection?
 EBL: estimate the amount of blood loss in cc’s
 Disposition: How did the patient tolerate the
procedure?
 Where will the patient go after the procedure?

44. Any Questions ??

45. References
 Maxwell Quick Reference Book. 2006.