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Medical Communications > Inpatient Documentation > Flashcards

Inpatient Documentation Flashcards

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USMLE® Step 1 flashcards
1
Q

Why document?

A
  1. To communicate to the others:
    - what is wrong
    - what has happened
    - what are your thoughts
    - who you talked to
    - what you did
  2. Medicolegal requirements - It did not happen if you did not write it down
    - Complete documentation is your best defense
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2
Q

Outpatient services (6):

A
  1. Cardiac diagnostic procedures
  2. Radiation Oncology
  3. Radiation
  4. Infusion - chemo or other
  5. Medical practices
  6. Surgery
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3
Q

Inpatient services (4):

A
  1. Emergency department
  2. Labor and delivery
  3. Medicine
  4. Surgery
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4
Q

How do you get into the hospital?

A
  1. Direct admission - scheduled or from the office
  2. Emergency department
  3. Labor and delivery
  4. Outpatient area - I.e., surgery & infusion services
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5
Q

Why admit to the hospital?

A

For care that cannot be delivered elsewhere (aka “cheaper”
1. Medical necessity:
- How sick is the patient? - acuity
- What is the risk to the patient?
2. Intensity of services:
- IV medications
- Monitoring requirements
- Intensive care
- Procedures or treatments

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6
Q

What happens in the hospital?

A
  1. Admission
  2. Stay
  3. Discharge
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7
Q

How do you leave the hospital?

A
  1. Front door - Home
  2. Side door - going/being transferred to somewhere else (I.e. Transfer (hospital), nursing home, rehab center, prison, other)
  3. Back door - Morgue
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8
Q

What is included in the History and Physical (H&P)?

A

It’s an expanded soap note:
Subjective - CC, HPI, ROS, PMH, FH, SH
Objective - Physical exam (PE), Diagnostic studies (x-ray, CT, bloodwork, etc.), laboratory, radiologic studies, etc.
Assessment - Problem or dx, differential diagnosis
Plan - What is it?, Why? (why do you think the problem is what you say it is), When? (need an appendectomy now), Who? (who will perform procedure or carry out orders)

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9
Q

The act of altering the medical record in a way that seems intentional (aka hiding something)

A

spoliation

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10
Q

Abbreviation are ___, not ___

A

regional; universal

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11
Q

What is included in a progress note?

A

Miniature soap SOAP note - documenting what has changed (if pt is progressing or not and when pt can go home)
- Subjective findings
- Objective - exam, lab, radiology, procedures (frequently documented with subjective portion)
- Assessment - anything different?
- Plan - changes to treatment (if any), anticipated disposition

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12
Q

How often is a progress note required?

A

at least daily (and every time there is a significant change to a patient’s status)

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13
Q

What 5 things are mandated to be in the Discharge Summary according to the Joint Commission for Accreditation of Hospitals?

A
  1. Reason for hospitalization
  2. Significant findings
  3. Procedures and treatments provided
  4. Patient’s discharge condition
  5. Patient instructions
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14
Q

What is included in the Discharge Instructions?

A
  1. Presenting problem
  2. Final diagnoses
  3. Medications
  4. Diet
  5. Therapies
  6. Follow up appointments
  7. Anticipated problems
  8. 24/7 call back number
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15
Q

In patients > 65 years, ___% recall their diagnosis and ___% recall follow up appointments. What does these stats infer?

A

60%; 46%
- Infers that patients are not getting the care they need and/or instructions were not given adequately

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16
Q

The National Patient Safety Foundation (2009) developed “Ask Me 3”, what is this and its purpose?

A

“Ask Me 3” are 3 questions to help the patient recall important info from their appointment:
1. Why was I in the hospital?
2. What do I need to do now?
3. Why is it important for me to do this?

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17
Q

What is a consult note and how is it different from H&P or a progress note?

A

A SOAP note from a specialist’s point of view:
- has much of the same info as a regular SOAP note (Subjective, Objective data) but interpreted from a different perspective.
- Ex: GI consult - expanded GI history and ROS; Cardiology - expanded cardiac history, ROS, exam
Make diagnoses and recommendations in their field - stay in your lane OR NOT
Consultants may write daily progress notes AS NEEDED
Consultants may sign off a case before discharge (they has nothing to do with discharge summary)

18
Q

______ - this process occurs when communication between a patient and physician results in the patient’s authorization and agreement to undergo a specific medical intervention

A

Informed consent

19
Q

What must be included during the informed consent process according to the AMA?

A
  1. Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
  2. Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include info about:
    - The diagnosis (when known)
    - The nature and purpose of recommended interventions
    - The burdens, risks, and expected benefits of all options, including forgoing treatment
  3. Document the informed consent conversation and the patient’s (or surrogate’s) decision in the medical record in some manner. When the patient/surrogate has provided specific written consent, the consent form should be included in the record.
20
Q

What is included in a procedure note?

A
  1. Date and Time
  2. Name of procedure
  3. Who did the procedure and who else was involved
  4. Statement that informed consent was obtained prior to procedure
  5. Type of anesthesia used and who administered it
  6. Procedure details:
    - What was done
    - Describe complications
    - Document blood loss
21
Q

What is the difference between a procedure note and an operative note?

A

Operative note is for procedures/surgeries occurring in the OR

22
Q

What are the operative note requirements per CMS (10)?

A

1.Name and hospital identification number of patient
2. Date and time of surgery
3. Name(s) of the surgeon(s) and all assistants who performed surgical tasks, even if under supervision
4. Pre-operative and post-operative diagnosis
5. Name of the specific surgical procedure(s) performed
6. Type of anesthesia administered, if any
7. Complications, if any
8. Narrative of procedure - a description of techniques, findings, and tissues removed or altered
9. Name(s) of surgeon(s) and assistant(s) and description of significant surgical task(s) performed by above named practitioners if different than primary surgeon
10. Prosthetic devices, grafts, tissues, transplants, or devices implanted, if any

23
Q

What is included in the transfer note?

A
  1. Reason for transfer to another hospital service or physical area (note would also be needed if patient was changing floors in the same hospital)
  2. Summary of care to date
  3. Current physical exam
  4. If transferring care to a new provider or care team, a statement documenting acceptance of transfer is required before the transfer is initiated.
24
Q

What would a physician be charged of if acceptance of transfer was not provided prior to transfer of patient?

A

Abandoment

25
Q

What are the additional elements of a Maternal H&P?

A
  1. Obstetrical history - number and outcome of previous pregnancies (gravidity and para); previous obstetrical complications
  2. Current obstetrical complications
  3. Current medications - potential teratogens (what causes birth defects)
  4. Current gestation in weeks
  5. Physical exam
  6. Tests indicative of current fetal health - fetal heart tones, USG, biophysical profile, results of non-stress test
26
Q

How many weeks is considered full term pregnancy?

A

~ 37 weeks

27
Q

What is the gravida for a woman’s first pregnancy? Second?

A

G1, G2

28
Q

What are the “4 digits” for para?

A

T - term (~37 weeks)
P - preterm
A - abortion
L - living pregnancy outcomes

29
Q

What would be the Gravida/Para abbreviation for 1 pregnancy and 1 abortion?

A

G1P001

30
Q

____ = the number of births >24 weeks gestation whether alive or stillborn

A

parity (aka para)

31
Q

What would be the Gravida/Para abbreviation for 1 pregnancy, 1 term birth?

A

G1P1

32
Q

Interpret the gravida/para abbreviation “G2P1203

A

2 pregnancies; 1 term birth, 2 preterm, 0 abortions, 3 living children => has twins

33
Q

Under what situation would a Delivery note require, in addition, all elements of an Operative note?

A

C-section

34
Q

According to the American College of Obstetrics and Gynecology, what must a delivery note include?

A
  1. Maternal-fetal assessment prior to delivery
  2. Labor details
  3. Delivery details
  4. Maternal status after delivery
  5. Complications, if any
  6. Blood loss
  7. Infant status
35
Q

How is an Infant H&P different from a standard one?

A

Will not include CC, ROS, or PMH (instead will have PRENATAL history)

36
Q

What is included in an ED note?

A
  1. Includes everything that is PERTINENT - only pertinent to current visit
  2. H&P
  3. Response, or lack of, to treatment
  4. Disposition
    - Discharge = home or back to from whence they came
    - Admit - to floor, ICU; to surgery
    - Morgue
37
Q

If the patient refuses treatment or leaves (Against Medical Advice), document the following:

A
  1. That you have explained your recommended treatment
  2. That you have offered the patient opportunity to ask questions
  3. That the patient decides to refuse or leave anyway
  4. That you have attempted to arrange follow-up for the patient
  5. That the patient may return at any time without any penalty
    - there is a form for the patient to sign if they are leaving AMA, they may refuse to sign it and you’ll just need to document that you tried
38
Q

“AADC” in “AADC VAAN DISSL” stands for:

A
  1. Admit
  2. Attend
  3. Diagnosis
  4. Condition
39
Q

The “VAAN” in “AADC VAAN DISSL” stands for:

A
  1. Vitals
  2. Activity
  3. Allergies
  4. Nursing procedures
40
Q

The “DISSL” in “AADC VAAN DISSL” stands for:

A
  1. Diet
  2. Ins and Outs (input and output)
  3. Symptomatic medications
  4. Special medications
  5. Labs

Medical Communications (5 decks)

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