Guide To Clinical Documentation 3rd Edition

Debra o· 5 ull1van
GUIDE TO
THIRD EDITION
GUIDE TO
Clinical
Documentation
THIRD EDITION
Debra D. Sullivan, PhD, RN, PA-C

Lead Advanced Practice Provider
Academic Urology and Urogynecology of Arizona
Litchfield Park, AZ
Owner, Sullivan Consulting Ser vices
Medicolegal Consulting
Glendale, AZ
00_Sullivan_FM.indd 1 7/5/18 5:15 PM

F. A. Davis Company
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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] |
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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!
Copyright © 2019 by F. A. Davis Company. All rights reserved. iii

Reviewers
Gilbert Boissonneault, PhD, PA-C, DFAAPA Sara Haddow Liebel, MSA, PA-C
Professor Education Director/Associate Professor
Division of Physician Assistant Studies Physician Assistant Department, College
Medical University of South Carolina of Allied Health Sciences
Charleston, SC Augusta University
Augusta, GA
Elizabeth Brownlee, MPAS, PA-C
Physician Assistant, Assistant Professor Nicole Schmitz, DNP, APRN, PNP, CHSE
School of Physician Assistant Studies, College Assistant Professor
of Medicine Nursing
University of Florida Minnesota State University – Mankato
Gainesville, FL Mankato, MN
Rhonda Glen Feldman, MHS, MSS, PA-C Emily K. Sheff, CMSRN, FNP, BC
Program Director Assistant Professor
Physician Assistant School of Nursing
University of New England MGH Institute of Health Professions
Portland, ME Boston, MA
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
Copyright © 2019 by F. A. Davis Company. All rights reserved. v

Acknowledgments
It is interesting to me how each edition of this book bring real-world knowledge and hands-on patient care
has its own uniqueness. I have worked at a different experience where I would only have been able to read
place during the writing of each edition, and I hope and write about what others do.
that has resulted in a deep layering of experience and There is a tremendous team of people at F. A. Davis
knowledge that makes each edition better. I certainly who have been part of this project. Even though he
feel like each job change has enhanced my professional retired before this edition was published, my dear friend
practice and has enriched me as a person. I have met Andy McPhee was the driving (cajoling? bullying?)
and worked with some extraordinary health-care force behind the third edition. I hope he is enjoying
providers, and I have had valuable contributions from his much-deserved retirement and getting to write
so many of them. what he wants, when he wants, if he wants. When
First, I would like to say thank you to my colleagues Andy approached me about a third edition, one of the
at Academic Urology and Urogynecology of Arizona. most anxiety-producing aspects of considering it was
I have had such encouragement and support from this who would be the developmental editor because I had
great group of people. I am grateful to have learned from less-than-wonderful experiences on the two previous
so many outstanding health-care providers throughout editions. I need not have worried at all, as I have had
my more than 27 years in medicine. I have benefitted the very good fortune to work with Stephanie Kelly,
from the expertise of Jamie Bair, NP (cardiology); developmental editor extraordinaire! Stephanie’s
Jennifer Nelson, PA-C (psychiatry); Steve Turner, knowledge of the process, her organizational skills,
RN (hospice); Dr. Richard Guthrie (palliative care); her sense of humor, and her hard work have made the
and several outstanding hospitalists who wished to journey so enjoyable, and she has my deepest gratitude.
remain nameless. I’m thankful for a group of dedicated I’m also grateful for the guidance of and contributions
Information Technology people who have helped me from Melissa Duffield, Senior Acquisitions Editor;
navigate electronic medical records and who’ve answered George Lang, Director of Content Development;
my questions with enthusiasm. Amelia Blevins, Developmental Editor for Digital
I must take this opportunity to acknowledge Products; Megan Suermann, Content Project Manager;
two incredible women who added so much to the Lori Bradshaw, Developmental Production Editor at
Document Library that we included in this edition S4Carlisle P ublishing; and Robert Butler, Production
of the book: Madison Palmer, MMS, PA-C, not only Manager. There’s probably not another publishing com-
contributed the prenatal records, but she also provided pany around that would have supported this project as
valuable assistance with content in the prenatal chapter. F. A. Davis has done, and I’m humbled and honored
Larissa J. Bech, MSN, RN, FNP-C contributed the they chose to champion this book.
pediatric records. Without their contributions, the
—Debbie Sullivan
prenatal and p ediatric visit notes would not exist. They
Copyright © 2019 by F. A. Davis Company. All rights reserved. vii

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 I SMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387
Copyright © 2019 by F. A. Davis Company. All rights reserved. ix

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 Purposes of Documentation 3
General Principles of Documentation 3
Medical Coding and Billing 5
Evaluation and Management Services 5
International Classification of Diseases Coding 6
Electronic Medical Records 8
Benefits of Electronic Medical Records 8
Barriers to Electronic Medical Records 9
Interoperability 9
Meaningful Use 9
Health Insurance Portability and Accountability
Act (HIPAA) 10
Health Insurance Portability 10
Electronic Health-Care Transactions 10
The Privacy Rule 10
Security Rule 13
Summary of the Act 14
Summary 14
Worksheets 15
Copyright © 2019 by F. A. Davis Company. All rights reserved. xi

xii | Contents
Chapter 2 The Comprehensive History and Physical Examination 23

Learning Outcomes 23
Introduction 23
Components of a Comprehensive History and Physical
Examination 23
History 24
Physical Examination 29
Laboratory and Diagnostic Studies 32
Problem List, Assessment, and Differential Diagnosis 32
Plan of Care 32
Sample Comprehensive History and Physical Examination 32
Summary 32
Worksheets 37
Chapter 3 SOAP Notes 45
Introduction 45
Subjective 45
Analyzing Documentation 47
Objective 48
Formats for Documenting Objective Information 49
Documenting Diagnostic Test Results 50
Interventions Done During the Visit 50
Assessment 52
Differential Diagnosis 53
Plan 54
Laboratory and Diagnostic Tests 54
Consults 54
Therapeutic Modalities 55
Health Promotion and Disease Prevention 55
Patient Education 55
Follow-Up Instructions 56
Summary 58
Worksheets 59
Copyright © 2019 by F. A. Davis Company. All rights reserved.

Contents | xiii
Part II: Documentation Related to Outpatient Care

Chapter 4 Documenting Prenatal Care and Perinatal Events 79
Introduction 79
Documentation of Prenatal Care 80
Demographic Information 80
Maternal History 80
Laboratory Data and Diagnostic Tests 82
Health Promotion and Disease Prevention 83
Documentation of Perinatal and Postpartum Care 83
Delivery Note 83
Postpartum Note 86
Newborn Physical Examination 87
Summary 87
Worksheets 89
Chapter 5 Pediatric Preventive Care Visits 93
Introduction 93
Components of Pediatric Preventive Care Visits 94
Growth Screening 94
Developmental Screening 98
Laboratory Screening Tests 99
Assessing Vaccination Status 100
Anticipatory Guidance 100
Risk Factor Identification 102
Age-Specific Physical Examinations 106
Pediatric Sports Preparticipation Physical Examination 106
Summary 109
Worksheets 111
Chapter 6 Adult Preventive Care Visits 125
Introduction 125

xiv | Contents
Documenting Preventive Care 126

Risk Factor Identification Based on Personal History 126
Risk Factor Identification Based on Family History 135
Risk Factor Identification Based on Screening Tests 135
Gender-Specific Screening 136
Health Education and Counseling 139
Assessing Vaccination Status 139
Summary 139
Worksheets 141
Chapter 7 Older Adult Preventive Care Visits 153
Introduction 153
Assessing Older Adult Risk Factors Through
History Taking 153
Medication Use 153
Functional Impairment 156
Nutrition 156
Sensory Deficit Screening 159
Mental Health Screening 160
Geriatric Syndromes 160
Assessing Older Adult Risk Factors Through
Sensory Examinations 161
Balance and Mobility Assessment 162
Cognitive Assessment 162
Additional Screening 162
Pre-operative Evaluation of Older Adults 162
Anticipating Future Needs 165
Advance Directives 165
Hospice and Palliative Care 166
Summary 166
Worksheets 167

Contents | xv
Chapter 8 Outpatient Charting and Communication 173

Introduction 173
Components of the Medical Record 173
Problem List 173
Medication List 176
Flow Sheets 179
Demographic and Billing Information 179
Results of Laboratory Studies and Other Diagnostic Tests 179
Noncompliance With Medical Treatment 179
Communication With Other Providers 182
Prior Medical Records 183
Documenting Communications With Patients 183
Telephone Communication 183
Electronic Mail 185
Patient Portal 187
Social Media 187
Benefits of Social Media 187
Concerns About Social Media 188
Provisions for Using Social Media 188
Summary 188
Worksheets 189
Chapter 9 Prescription Writing and Electronic Prescribing 195
Introduction 195
Federal and State Regulations and Prescribing Authority 196
Safeguards for Prescribers 197
Controlled and Noncontrolled Substances 199
Elements of a Prescription 199
Writing Prescriptions for Noncontrolled Medications 199
Prescriber Identification 199
Patient Identification 199

xvi | Contents
Inscription 200
Subscription 200
Signa or sig 200
Indication 200
Refill Information 200
Generic Substitution 201
Warnings 201
Container Information 201
Signature 201
Writing Prescriptions for Controlled Medications 201
Common Errors in Prescription Writing 202
Electronic Prescribing 203
Federal Initiatives for Electronic Prescribing 204
Qualified Electronic Prescribing 204
Benefits of E-Prescribing 205
Barriers to E-Prescribing 206
Summary 206
Worksheets 207
Part III: Documentation Related to Inpatient Care

Chapter 10 Admitting a Patient to the Hospital 217
Introduction 217
Admission History
and Physical Examination 218
Medical Admission History
and Physical Examination 218
Surgical Admission History and Physical Examination 221
Sample H&P 223
Admission Orders 223
Admit 227
Diagnosis 227
Condition 227
Activity 227

Contents | xvii
Vital Signs 227

Allergies 228
Diet 228
Interventions 228
Medications 228
Procedures 229
Laboratory and Other Diagnostic Studies 229
Special Instructions 229
Perioperative Orders 229
Admit 230
Diagnosis 230
Condition 230
Activity 230
Vital Signs 230
Allergies 230
Diet 230
Interventions 232
Medications 232
Procedures 233
Laboratory and Other Diagnostic Studies 233
Special Instructions 234
Computerized Physician Order Entry 234
Benefits of CPOE 235
Challenges and Barriers to CPOE 235
Admit Notes 237
Summary 238
Worksheets 239
Chapter 11 Documenting Inpatient Care 257

Introduction 257
Daily Progress Note 257
Content of a Daily Progress Note 257
Daily Orders 260

xviii | Contents
Consult Note 266

Full Operative Report and Operative Note 271
Other Types of Documents 272
Procedure Note 272
Summary 274
Worksheets 275
Chapter 12 Discharging Patients from the Hospital 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

Contents | xix
Appendices
Appendix A Document Library 309
Appendix B A Guide to Sexual History Taking 373
Appendix C I SMP’s List of Error-Prone Abbreviations, Symbols,
and Dose Designations 375
Bibliography 377
Index 387

Introduction
It’s no secret that medicine is constantly changing and chapters and to provide much more detail about the
evolving, but I guess I didn’t realize that there have been content. New content includes Chapter 4, Documenting
so many changes and evolutions in documentation until Prenatal Care and Perinatal Events, and Chapter 7,
I started working on the third edition. Since the second Older Adult Preventive Care Visits. Some chapters were
edition was published in 2011, there have been signif- relocated within the text to present a more chronological
icant changes in coding, billing, reimbursable services, sequence. Every chapter was revised; some revisions were
federal requirements for documentation, platforms for fairly minor, whereas others were extensive. Medicolegal
documentation, and so on. And, thanks to the feedback Alerts are included in each chapter to help highlight
from users of this text and thoughtful reviews by edu- important concepts. New to this edition are images of
cators and practitioners, the “wish list” of content for electronic medical record (EMR) entries, or screen shots.
this text has changed as well. So, here you have it, the There are multiple EMR systems available, so what is
third—and by far, the best—edition. One thing that presented may look different from what you’ve seen
has not changed is the basic principle of the book—this before, but I think it is helpful to see sample entries
is an instructional work on documentation and is not from different systems.
meant to be an instructional work on the practice of Sometimes Appendices don’t get a lot of attention,
medicine. Documentation and the practice of medicine but I hope you’ll check out Appendix A, the Document
are interrelated, and it is sometimes a challenge to keep Library. In the library, you’ll find documents that per-
them separate. However, they are two distinctly differ- tain to a particular patient grouped together in a way
ent practices. As an educator, I teach. As a Physician that captures the patient’s care chronologically. This
Assistant, I practice medicine. As an author, sometimes provides a different perspective than seeing them as
I want to do both, but that has never been the goal. “stand-alone” documents in multiple chapters.
The goal is to provide a solid foundation of principles Many educators mentioned that they would like the
of documentation that will preserve important aspects worksheet answers moved out of the book so that they
of the health-care provider–patient encounter while could be used more effectively as an educational tool,
meeting the requirements for reimbursement and other so this was done. You can find them in the Instructor’s
regulations. There are many examples of documenta- Guide, at DavisPlus on the F.A. Davis website, which
tion of various encounters throughout this book, and will allow you to provide them to the students as you
each is just one example of how an encounter may be see fit—you can simply provide the answers so students
documented. There is not just one way to document can check their own work, or you can use the worksheets
any encounter but many different ways; and different as graded assignments.
doesn’t mean “good” and “bad”—just different. I’m of Whether you are a student, a novice practitioner, or an
the opinion that the more examples you see, the more experienced provider, I hope this book will be a valuable
you will learn and the more prepared you will be when resource in your journey of professional development.
it comes time for you to document your way.
—Debbie Sullivan
Revisions started with the Table of Contents, which
Phoenix, Arizona
has been expanded to highlight sections within the
Copyright © 2019 by F. A. Davis Company. All rights reserved. xxi

PART I Foundations of Documentation
Chapter 1
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.
documentation and puts a greater burden on providers

Introduction to capture their thoughts and actions for others to read
and interpret years after an episode of care took place.
You might be asking, “Why a book on documentation?”
Dr. Mitchell Cohen wrote about this evolution of
Documentation is one of the most important skills a
documentation in an article that appeared in Family
health-care provider can learn. You might feel tempted
Practice Management.* Dr. Cohen explains:
to focus considerably more time and energy on learning
other skills, such as physical examination, suturing, or From time to time I’ll stumble upon an old chart in my
pharmacotherapeutics. These are essential skills, but office that goes back 40 years. My predecessors charted
documentation is likewise extremely important. State office visits on sheets of lined manila card stock, which
licensure laws and regulations, accrediting bodies, would suffice for at least 15 to 20 visits. Clearly, these
professional organizations, and federal reimbursement charts were only intended for the physicians as a way to
programs all require that health-care providers maintain refresh their memory of what happened from one visit to
a record for each of their patients. the next. For example, the documentation for one visit
Documentation used to be mostly a memory aid read simply, “1/20/67: pharyngitis >> penicillin.” These
for the provider—a quick note of his or her thoughts days chart notes are primarily not for the physician or
about a patient’s presentation, a likely diagnosis, maybe patient, but for all the others who aren’t in the exam
a few words about the treatment plan. Over the past room and yet feel they have a stake in what takes place
few decades, however, documentation has become a in this once confidential arena. To satisfy coders and
more complex task due to changes in medicine and insurers, my documentation for a 99213 sore throat
with patients themselves. Increased complexity in the visit must contain one to three elements of the history
medical field is evident by the ever-increasing number of present illness, a pertinent review of systems, six to
of medications and treatment modalities available to 11 elements of the physical exam, and low-complexity
health-care providers. In addition, patients live longer medical decision-making. My malpractice carrier and
with a greater number of comorbid conditions, adding my future defense attorney would also like me to explain
to the complexity of caring for them and requiring that my clinical rationale for why the patient has strep throat
complexity in the medical records. The fact that our so- and not a retropharyngeal abscess or meningitis. A table
ciety is so litigious certainly adds more weight to clinical with a McIsaac score calculating the likelihood that this
1
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2 | Guide to Clinical Documentation
patient does indeed have strep throat might be nice as record also serves other purposes and has audiences
well. If I prescribe a weak narcotic for a really nasty other than the patient and the health-care provider; it is
case of strep, the state medical board would be pleased both a medical and a legal document. The medical record
if I addressed what other medications have been tried establishes your credibility as a health-care provider. It
and whether the patient has any history of addiction. is important to remember that you are creating a record
I’ll also need to document that I explained the proper that other professionals will read; therefore, you should
use of the medications and the need for follow up if the use professional language and include appropriate
patient doesn’t get better. When I’m finally done with content. Other readers will assume, rightly or wrongly,
my note, it looks like this: that you practice medicine in much the same way that
you document. If your documentation is sloppy, full
CC: sore throat x 2d of errors, or incomplete, others will assume that is the
HPI: 17 y/o F with 2d h/o sore throat. Has an asso- way you practice. Conversely, thorough, legible, and
ciated headache and fever to 1018F. No significant complete documentation will infer that you provide
cough. Patient has noticed some swollen lumps in care in the same way, thus establishing your credibility.
neck. Having significant pain despite use of Tylenol, Some excellent providers simply do not have good doc-
ibuprofen and salt water gargles. umentation skills. However, this is the exception rather
Social Hx: no h/o substance abuse or addiction. than the rule. It is very difficult to persuade those who
ROS: denies neck stiffness or back pain, no rash. No read sloppy documentation that the person who wrote
difficulty speaking. that way can, and did, provide good care.
PE: VS: AF, VSS Up-to-date and complete documentation is an essential
Gen: alert, pleasant female in NAD component of quality patient care. The medical record
HEENT: NC/AT, PERRLA, EOMI, TM clear b/l, is the primary means of communication between mem-
OP notable for tonsillar enlargement with exudates. bers of the health-care team and facilitates continuity
No asymmetry or uvular deviation present. of care and communication among the professionals
Neck: + tender anterior cervical adenopathy, no nuchal involved in a patient’s care. Although many patients
rigidity or meningismus. will have a primary care provider who provides most of
CV: RRR S1/S2 without murmurs. their care, patients also may see specialists for specific
C/L: CTAB problems. Medical records are the vehicle for com-
Abd: soft, nondistended, nontender, no hepatosplenomegaly. munication among members of the health-care team,
McIsaac’s score = 4; Rapid strep + and the medical record is the common storehouse for
A: streptococcal pharyngitis all information about the patient’s care and condition
P: 1) Pen VK 500 mg po TID x 10 days. Discussed regardless of who is providing that care.
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- Legal Considerations
ticularly when trying to rest. Has already tried
acetaminophen and NSAID and will continue salt
of Documentation
water gargles. Follow up if no improvement in one As mentioned previously, all medical records are legal
week. Have discussed other potential diagnoses and documents and are important for both the health-
reviewed warning signs of retropharyngeal abscess care provider and the patient, regardless of where the
and meningitis. Patient agrees and understands plan. patient care takes place. The most important legal
functions of medical records are to provide evidence
Like I said, “pharyngitis >> penicillin.” that appropriate care was given and to document
(*Used with permission of the American Academy of the patient’s response to that care. An often-quoted
Family Physicians) 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
Medical Considerations is impossible to capture with documentation every
nuance of a patient–provider encounter, and it is im-
of Documentation possible to create a perfect record of every encounter.
However, the principle behind the quote is important
As illustrated in the example, the medical record serves in a legal context; there is a considerable time lapse
to document the details of the patient’s complaint and between when events occur (and are documented)
the medical evaluation and treatment. The medical and when litigation occurs. It may be anywhere from

Chapter 1 Medicolegal Principles of Documentation | 3
2 to 7 years from the occurrence of an event until you Clear and concise documentation is required to receive
are called to give a sworn account of the event. The accurate and timely payment for furnished services.
medical record is usually the only detailed record of Peer-review organizations might read the record to
what actually occurred, and only what is written is determine whether the care reflected in your doc-
considered to have occurred. You will not remember umentation is consistent with the standard of care.
the details of an event that happened 6 years ago; your Researchers often obtain access to medical records for
only memory aid will be the medical record. As a legal purposes of conducting scientific studies. Although it
document, the medical record that you authored will be is important to remember that these audiences may
made available to plaintiff attorneys, defense attorneys, have access to your records, you should keep in mind
malpractice carriers, jurors, judges, and, most likely, that the primary audience of the medical records will
the patient. You should keep this in mind at all times be medical professionals involved in direct patient care.
when documenting. Throughout this book, you will analyze examples of
The record should be objective. Personal, subjective documentation. You may also complete the worksheets,
opinions regarding the patient, the patient’s family, or which will help you apply the information as you read
other providers do not belong in the medical record. It it. The purpose of this book is to teach documentation
is human nature to make value judgments about others, skills and critical analysis of medical records, not to
but it is asking for trouble to note in a record those instruct on the practice of medicine or to teach medical
irrelevant judgments about the patient. Document facts; decision-making. The content of a medical record—or
not opinions. All providers should strive for accuracy learning what to document—varies greatly, depending
in documentation. Correcting a medical record is not on the patient’s presenting problem or condition. The
only encouraged, but it is necessary in order to avoid principles of how to document and why documentation
potentially harmful mistakes or misrepresentations. is important do not vary as much and, thus, are the
Altering a record should never be done. Alteration con- focus throughout this book.
notes an improper change, concealment, or omission of
portions of records that were written inappropriately.
Correction implies the act of making something right. General Principles
Record alterations have rendered many defensible cases
indefensible. Most jurors will suspect that a provider of Documentation
who alters records has done so to cover up a mistake.
The Centers for Medicare and Medicaid Services (CMS)
The opposing attorney will argue that alteration shows
is one agency of the U.S. Department of Health and
consciousness of guilt. Alterations in medical records
Human Services (HHS). As one of the nation’s largest
may give rise to a claim for punitive damages against a
payers for health-care services, CMS has established
provider. Intentionally altering or destroying a patient’s
specific guidelines for documentation that are referenced
chart is considered unprofessional conduct. Most states
several times throughout this book. There are two sets of
will consider a practitioner who alters or destroys a
documentation guidelines currently in use: the 1995 and
patient’s chart to have violated the applicable licensing
the 1997 guidelines. CMS published an evaluation and
statute and will sanction or suspend the practitioner’s
management guide in 2015; however, it was offered as a
license to practice medicine.
reference tool and did not replace the content found in
the 1995 and 1997 guidelines. There are minor differences
Other Purposes between the two guidelines, and it is recommended
that health-care providers refer to the guidelines to
of Documentation identify those differences. Additional information may
be found at www.cms.gov/Outreach-and-Education/
Reviewers from various organizations can obtain Medicare-Learning-Network-MLN/MLNProducts/
access to a medical record for a variety of purposes. Downloads/eval-mgmt-serv-guide-ICN006764.pdf.
Health-care payers require reasonable documentation Both sets of guidelines recognize the following
for a number of reasons: general principles of documentation:
• To ensure that a service is consistent with the pa- 1. The medical record should be complete and
tient’s insurance coverage legible.
• To validate the site of service, medical necessity, 2. The documentation of each patient encounter
and appropriateness of the diagnostic and/or should include the following:
therapeutic services provided • Reason for the encounter and relevant history,
• To confirm that services furnished were accurately physical examination findings, and diagnostic
reported test results

• Assessment, clinical impression, or diagnosis systems create a “digital footprint” every time a record
• Plan for care is accessed. This digital footprint includes the date and
• Date and legible identity of the health-care time and the identity (typically name and title and/or
provider role) of the person accessing the record. The system
3. If not documented, the rationale for ordering also will indicate the time and date of any updates or
diagnostic and other ancillary services should be changes made to the record. You should never document
easily inferred. in a patient’s record in advance of seeing the patient. In
4. Past and present diagnoses should be accessible addition, you can correct or amend a patient’s medical
to the treating and consulting providers. record, but you should never alter it. At times, it will
5. Appropriate health risk factors should be be necessary to make corrections to a record. When
identified. making a correction in a paper record, you should draw
6. The patient’s progress, response to and changes a single line through the text that is erroneous, initial
in treatment, and revision of diagnoses should be and date the entry, and label it as an error. If there is
documented. room, you may enter the correct text in the same area
7. The diagnosis and treatment codes reported on of the note. You should not write in the margins of a
the health insurance claim form or billing state- page; if there is no room to enter the correct text, use
ment should be supported by the documentation an addendum to record the information. You should
in the medical records. (More discussion of bill- never obliterate an original note, nor should you use
ing and coding is included later in this chapter.) correction fluid or tape. In the EMR, once a document
is submitted, it is still possible to modify or correct
There are other generally accepted principles of the record. If an entire entry is incorrect (for exam-
documentation, such as that each entry should include ple, charting on the wrong patient), there is a process
the date and time the record was created and should to identify the entry as an erroneous document. The
identify the person creating the record. In settings in process will vary with different EMR systems, and
which care is provided around the clock, military time institutions will have their own policy for identifying
is often used to avoid confusion between a.m. and p.m. erroneous entries.
One o’clock in the afternoon is 1300, 10:30 at night is Based on your reading, complete the application
2230, and so forth. Electronic medical record (EMR) exercise that follows.
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
HUURUGV=RFRUPJGDLO\PHWIRUPLQPJGDLO\6\QWKURLGPJGDLO\
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.
If using a ruled sheet such as an order sheet or not read” or “dictated but not reviewed” because doing
progress note, be sure that there are no blank lines. so will call attention to the fact that you did not verify
If a record is dictated and then transcribed, read the the content of the record.
transcription before signing it, correcting any errors in When entering the medical field, you must learn the
the process. You should not stamp a record “signed but language in order to function. Part of learning this language

is to learn the meaning of the abbreviations, acronyms, with a hyphen. The third category of CPT codes cor-
and symbols in use; therefore, they are incorporated in responds to emerging medical technology. There are
this text. Abbreviations are a convenience, a time saver, approximately 7,800 CPT codes, and the codes are
a space saver, and a way of avoiding the possibility of updated annually.
misspelled words. Incorporating abbreviations is not
an endorsement of their legitimacy, but it is intended Evaluation and Management Services
to assist individuals in reading and understanding When a patient presents for care, you as the health-care
medically related documents. Sometimes abbreviations provider evaluate the patient and then proceed to manage
are not understood. They can be misread or interpreted the presenting complaint. That encounter between you
incorrectly. For example, the abbreviation “CP” could and the patient may vary from brief to comprehen-
mean “chest pain” or “cerebral palsy.” Of course, the rest sive depending on the patient’s chief complaint. For
of the entry should make clear the term for which the example, the time required for evaluation of a child
abbreviation is being used. There are variations in how who presents with a sore throat is typically brief, and
an abbreviation can be expressed. “Anterior-posterior” the management options are fairly straightforward.
has been written as AP, A.P., A/P. Abbreviations may Conversely, more time is required for evaluating an
appear as all uppercase or all lowercase, and they may older adult who has several chronic conditions and a
or may not have periods after each letter (for example, new complaint of chest pain, and the evaluation and
PRN, prn, P.R.N., meaning “as needed”). Many inherent management process is more complex.
problems associated with abbreviations contribute to CPT codes assigned for E/M services are deter-
or cause errors. Health-care organizations should for- mined by several factors. One factor is whether the
mulate a “Do Not Use” list of dangerous abbreviations, patient is new, established, or seen for consultation
and you as the health-care provider are responsible for services, and another is the setting where care is
complying with your institution’s policies regarding provided. Complexity of service is another factor
use of abbreviations. and is determined by three key elements: history
(including history of present illness [HPI]; review of
systems [ROS]; and past medical, family, and social
Medical Coding and Billing history [PMFSH], which are explored in Chapter 2),
physical examination, and medical decision-making.
Concise documentation of the medical encounter is The complexity considers the presenting complaint,
critical to providing patients with quality care and to co-existing medical problems, amount of data to be
ensuring accurate and timely reimbursement. Medi- reviewed (i.e., tests and old records), amount of time
cal records are subject to review by payers to validate that you spend with the patient, number of diagnoses
that the services provided were medically necessary and treatment options, and risk for significant com-
and were consistent with the individual’s insurance plications. Table 1-1 summarizes the requirements for
coverage. Standard codes are assigned to reflect the each level of E/M based on history, physical exam-
health-care diagnosis, procedures, and medical ser- ination, and complexity of medical decision-making.
vices provided and to create a uniform vocabulary In the case where counseling and/or coordination
for claims processing, medical care review, medical of care constitutes more than 50% of the encounter,
education, and research. Two important code sets are time is considered the key or controlling factor to
the Current Procedure Terminology (CPT) and the qualify for a particular level of E/M services. This
International Classification of Diseases (ICD) codes. includes time spent with parties who have assumed
CPT codes are used to document many of the med- responsibility for the care of or decision-making for
ical procedures performed in a physician’s office. This the patient. If you elect to report the level of service
code set is published and maintained by the American based on counseling and/or coordination of care, then
Medical Association (AMA). CPT codes are five-digit you would document the total length of time of the
numeric codes that are divided into three categories. encounter, and you should describe in the record the
The first category is used most often, and it is divided counseling and/or activities performed to coordinate
into six ranges that correspond to six major medical care. Counseling includes discussion of diagnostic
fields: Evaluation and Management (E/M; discussed results, impressions, and/or recommended diagnostic
in more detail next), Anesthesia, Surgery, Radiology, studies; prognosis; risks and benefits of management
Pathology and Laboratory, and Medicine. The second options; instructions for management and/or follow-up;
category of CPT codes corresponds to performance importance of compliance with chosen management
measurement and, in some cases, laboratory or radiology (treatment) options; risk factor reduction; and patient
test results. Typically, these five-digit, alphanumeric and family education. An example of documentation
codes are added to the end of a Category I CPT code of time spent with a patient is shown in Example 1.1.

Table 1-1 Levels of Evaluation and Management Based on History, Physical Examination,
and Complexity of Medical Decision-Making
Level of History HPI ROS PMFSH
Problem focused Brief (one to three elements) None None
Expanded problem Brief (one to three elements) One system None
focused
Detailed Extended (four or more Two to nine systems One pertinent PMFSH (one
elements) from any of the three)
Comprehensive Extended (four or more 10 or more systems Complete PMFSH
elements)
Type of Physical
Examination Examination Description 1995 Guidelines 1997 Guidelines
Problem focused Limited to affected body area or One body area or organ One to five bulleted items
organ system system
Expanded problem Affected body area/organ system Two to seven body areas Six to 11 bulleted items
focused and other symptomatic or or organ systems
related organ system(s)
Detailed Affected body area/organ system Two to seven body areas 12 to 17 bulleted items for
and other symptomatic or or organ systems two or more systems
related organ system(s)
Comprehensive General multisystem Greater than eight body 18 or more for nine or
areas or organ systems more systems
Amount of Data Risk for Complications,
Medical Number of Treatment (Diagnostic Studies, Morbidity and/or
Decision-Making Options Prior Records) 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
EXAMPLE 1.1 mortality and morbidity statistics. These standardized

J.K. is a 62-year-old established patient who comes
codes are used by national and international agencies
in to discuss use of cholesterol lowering medication.
and organizations to forecast health-care needs, evaluate
More than half of the time of the encounter was spent
facilities and services, review costs, and conduct studies
providing patient education and counseling, and you
of trends in diseases over the years. ICD was established
document the following:
by the World Health Organization in the late 1940s
and has been updated several times in the years since
A total of 15 minutes was spent face-to-face with the patient its inception. The number following “ICD” represents
during this encounter, and over half of that time was spent which revision of the code is in use; therefore, “ICD-10”
on counseling. We discussed in-depth the results of his most represents the 10th revision. ICD-10 has more than
recent labs, specifically high cholesterol and triglyceride levels, 155,000 codes and has the capacity to accommodate
his risk factors for coronar y disease (smoking, high cholesterol, new diagnoses and procedures, expand descriptions of
and family histor y), and the importance of primar y prevention some diagnoses, and allow more detailed tracking of
of coronar y disease with aggressive treatment of high choles- mortality and morbidity. The ICD codes are updated
terol. I also educated the patient about lifestyle modifications every October; therefore, health-care providers and
that may improve blood pressure and help lower cholesterol. 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,
International Classification of Diseases symptom, condition, problem, complaint, or other reason
Coding for the encounter. When assigning a diagnosis and code,
Whereas CPT codes indicate what services and procedures you should be as descriptive as the data allow and use
were provided, the ICD codes explain the reason for the medical terminology rather than lay terminology. For
services. The ICD code is a diagnostic coding system example, instead of documenting “runny nose,” you should
that classifies diseases and injuries and is used to track use “rhinorrhea.” This does not work in every situation;

there is no medical term for “chest pain” when used as The primary code would be abdominal pain
a diagnosis, unless you know what is causing the chest (R10.10 if upper abdominal pain or R10.30 if
pain. When claims are submitted for payment, both CPT lower abdominal pain).
and ICD codes are provided, and your documentation 4. Secondary codes are listed after the primary code
must support the level of service billed. CPT codes work and expand on the primary code or define the
in tandem with ICD codes to create a full picture of need for a higher level of service.
the medical process for the payer; “this patient arrived • In the previous example, if the patient with
with these symptoms (as represented by ICD codes) abdominal pain has bloody vomitus, then
and these procedures were performed” (represented by hematemesis (K.92) would be coded as a
CPT codes). Downcoding is the process by which an secondary diagnosis.
insurance company reduces the value of a procedure or 5. Code a chronic condition as often as applicable
encounter and resulting reimbursement because either to the patient’s condition.
(1) there is a mismatch of CPT code and description, • Using example 3, the patient’s history of de-
or (2) the ICD code does not justify the procedure or pression may not be pertinent to the complaint
level of service. The quality and accuracy of the medical of abdominal pain, so it would not be coded;
record are vital to the reimbursement process, which, in however, diabetes would be coded.
turn, is vital to the delivery of health care. 6. Code co-existing conditions that may have an
influence on the outcome.
MEDICOLEGAL ALERT ! • In example 3, depression is a co-existing
condition that may alter a patient’s percep-
Although getting paid is a very important issue for tion of abdominal pain. The patient may take
health-care providers, you should never code for re- antidepressant medication, which could cause
imbursement purposes only. This can be construed as the pain. Coding both the chronic condition
fraud. Remember, your documentation must support the (diabetes) and co-existing condition (depres-
level of service and the diagnoses reported. sion) demonstrates the higher level of care
needed to manage the patient.
7. Do not use “rule out . . .” as a diagnosis.
Good documentation is absolutely essential to support • There is no code for this. Instead, use a
the level of E/M services and facilitate assignment of diagnosis, symptom, condition, or problem.
correct CPT and ICD codes. Here are some key con- You may use “rule out” when documenting the
cepts showing the interrelatedness of documentation assessment to guide you in your plan of care,
and codes and an illustrative example of each concept: although it is not necessary.
8. Signs and symptoms that are routinely associ-
1. Any tests ordered must correlate with an ICD
ated with a disease process should not be coded
code assigned to the visit.
separately.
• If a urine pregnancy test is performed, a rea-
• An upper respiratory infection (URI) is typ-
son for obtaining that test must be associated
ically associated with pharyngitis, rhinitis,
with a diagnosis, such as secondary amenor-
and cough. Pharyngitis, rhinitis, and cough
rhea (N91.1), menometrorrhagia (N92.0), or
each have a distinct ICD-10 code ( J02.9, J00,
abdominal pain (R10.10 if upper abdominal
and R05, respectively), but the code for URI
pain or R10.30 if lower abdominal pain).
( J06.9) is used because it encompasses these
2. Assign an ICD code that reflects the most
symptoms.
specific diagnosis that is known at the time. 9. When the same condition is described as both
• A patient’s diagnosis is gastroenteritis (K52.9). acute and chronic, code both and use the acute
If it is reasonably certain that it is viral, use the code first.
code for viral gastroenteritis, A08.4. Suppose • A patient may have an acute exacerbation
that the patient’s original complaint was di- ( J01.90) of chronic sinusitis ( J32.9).
arrhea (R19.7). The result of a stool culture is
positive for shigella. When the patient returns Accurate billing and coding is necessary to capture as
for a follow-up visit, then the diagnosis would much revenue as possible. The information presented
be enteritis, shigella (A03.9). here is meant to be illustrative in nature and is by no
3. The primary code should reflect the patient’s means adequate treatment of the subject and should not
chief complaint or the reason for the encounter. be relied on as authoritative. Many excellent resources
• A patient with a history of depression and are readily available to assist those who desire more
diabetes presents with acute abdominal pain. information on this topic.

Electronic Medical Records an electronic medical records system should be capable

of performing:
In just a decade, medical documentation has transi- 1. Health information and data
tioned from mostly paper records to mostly electronic 2. Result management
records. Much of the stimulus for adoption of EMRs 3. Order management
is the increasing evidence that current systems are not 4. Decision support
delivering sufficiently safe, high-quality, efficient, and 5. Electronic communication and connectivity
cost-effective health care. According to HHS, 78% 6. Patient support
of office-based physicians and 59% of hospitals use 7. Administrative processes
a basic EMR system. EMR lies at the center of any 8. Reporting
computerized health system. The EMR is a longitudinal
electronic record of patient health information gen- A closer look at the intended functionality in each
erated by one or more encounters in any care delivery of these eight areas identifies some of the perceived
setting. Several interchangeable terms may be used for benefits of EMRs. An electronic system would provide
EMR, such as electronic health record (EHR), electronic immediate access to key information, such as diagnoses,
patient record (EPR), and computer-based patient record allergies, laboratory test results, and medications, that
(CPR). A more comprehensive definition of EMR is would improve the provider’s ability to make sound
provided by the 1997 Institute of Medicine report, The clinical decisions in a timely manner. Result manage-
Computer-Based Patient Record: An Essential Technology ment would ensure that all providers participating in
for Health Care: the care of a patient would have quick access to new
and past test results, regardless of who ordered the
A patient record system is a type of clinical information tests, the geographic location of the ordering provider,
system, which is dedicated to collecting, storing, ma- or when the tests were ordered or performed. Order
nipulating, and making available clinical information management would include the ability to enter and
important to the delivery of patient care. The central store orders for prescriptions, tests, and other services
focus of such systems is clinical data and not financial in a computer-based system that would enhance leg-
or billing information. Such systems may be limited in ibility, reduce duplication, reduce fragmentation, and
their scope to a single area of clinical information (e.g., improve the speed with which orders are executed.
dedicated to laboratory data), or they may be comprehensive Using reminders, prompts, and alerts, computerized
and cover virtually every facet of clinical information decision-support systems would improve compliance
pertinent to patient care (e.g., computer-based patient with best clinical practices, ensure regular screen-
records systems). ings and other preventive practices, identify possible
The electronic storage of clinical information will create drug–drug or drug–disease interactions, and facilitate
the potential for computer-based tools to help providers diagnoses and treatments. Electronic communication
significantly enhance the quality of medical care and and connectivity would provide efficient and secure
increase the efficiency of medical practice. These tools communication among providers and patients that would
may include reminder systems that identify patients improve the continuity of care, increase the timeliness
who are due for preventive care interventions, alerting of diagnoses and treatments, and reduce the frequency
systems that detect contraindications among prescribed of adverse events. Patients would be provided tools that
medications, and coding systems that facilitate the give them access to their health records and interactive
selection of correct codes for patient encounters. The patient education and that would help them carry out
potential of such tools will not be realized, however, if home-monitoring and self-testing to improve control of
the EMR is just a set of textual documents stored in chronic conditions. Computerized administrative tools,
a computer, that is, a “word-processed” patient chart. such as scheduling systems, would improve hospitals’
To support intelligent and useful tools, the EMR must and clinics’ efficiency and provide more timely service to
have a systematic internal model of the information patients. Electronic data storage that employs uniform
it contains and must support the efficient capture of data standards will enable health-care providers and
clinical information in a manner consistent with this organizations to respond more quickly to federal, state,
model. and private reporting requirements, including those that
support patient safety and epidemiological and disease
surveillance. Such data could be readily analyzed for
Benefits of Electronic Medical Records medical audit, research, and quality assurance and could
A 2003 report by the Institute of Medicine, Key Capa- provide support for continuing medical education.
bilities of an Electronic Health Record System, identified Electronic prescribing, or e-prescribing, is a specialized
a set of eight core health-care delivery functions that function within a computerized medical record system.

Specific legislation and regulations exist that dictate such as patient records, cannot easily be shared across
the use of electronic prescribing. This is discussed in and sometimes within enterprises. There are signifi-
detail in Chapter 9. cant barriers to achieving interoperability. Incredibly,
there are over 1,000 EMR platforms on the market.
Barriers to Electronic Medical Records Most of these systems are highly proprietary and may
Many perceived barriers have hampered widespread not communicate well with each other. This lack of
implementation of EMRs. Although numerous studies interoperability presents a barrier to the transparent
have shown that most health-care providers believe that communication of health information, preventing
use of EMRs will improve quality of care, reduce errors, adequate coordination of care on the small scale and
improve quality of practice, and increase practice produc- obstructing population health management on a larger
tivity, there is resistance to adopting EMRs. A number scale. There is no standard technical language shared
of factors contribute to this, including well-publicized between systems; hence, there is little or no integra-
EMR failures; limited computer literacy on the part of tion with other applications, nor is there the ability
providers; concerns over security, productivity, patient of different systems to communicate in a meaningful
satisfaction, and unreliable technology; and the ab- way with one another. Information technologies were
sence of reputable research substantiating the benefits not initially designed with interoperability in mind, so
of EMR. Market and economic factors are a concern. rarely are structures in place to support it. Currently
Apart from the costs of hardware and software, there used data storage systems are often proprietary, and
is a tremendous cost in staff time and revenue when access to these systems is difficult. Implementation of
switching from paper to electronic charts. Ethical interoperable health information systems may require a
and legal issues abound with concerns about safety high degree of technical expertise not readily available
and security of systems and the ability to protect and to individual providers or smaller health-care organiza-
keep private confidential health information. There is tions. Standards of interoperability are only just being
even disagreement over who “owns” the data entered developed—after many health information technology
into any system as well as debate about accessibility to systems have already been installed and implemented.
the data. Technical matters, such as functionality, ease Meeting standards of operability will be an important
of use, and customer support from vendors are other criterion for the certification of EMR systems that are
barriers. It is challenging enough to find an EMR being developed at this time.
system that works for a single-provider ambulatory
care–based practice; it is another challenge altogether Meaningful Use
to find a system that will work for large institutions In February 2009, President Obama signed into law the
and serve the needs of diverse departments. Providers American Recovery and Reinvestment Act (ARRA) of
often complain that EMRs interfere with clinical 2009, which included more than $48 billion for health-care
care, making interactions more impersonal and less information technology for the adoption and effective use
face-to-face while also degrading clinical documentation. of EMR and for regional health information exchange.
Despite the huge investments that have been made in The Health Information Technology portion of ARRA
new technology, there are conflicting opinions about contains information related to the Health Information
the value of EMRs and whether or not they will truly Technology for Economic and Clinical Health Act
help improve quality of care while decreasing costs. A (HITECH); the HITECH Act offers financial incen-
recent study by Medical Economics indicated that 67% tives for health-care providers and hospitals that comply
of physicians are displeased with their EMR systems. with the standards of “meaningful use.” To receive an
incentive payment, providers have to show that they are
Interoperability “meaningfully using” their certified EMR technology
Perhaps the biggest barrier to widespread adoption of by meeting certain measurement thresholds that range
EMR is lack of interoperability. A basic definition for from recording patient information as structured data to
interoperability is the ability of two or more systems or exchanging summary care records. The HITECH Act
their components to exchange information and to use imposes requirements for notification of a data breach
the information that has been exchanged. As it relates related to unauthorized uses and disclosures of “unsecured
specifically to EMRs, the Healthcare Information protected health information” (PHI). These notification
and Management Systems Society (HIMSS) defines requirements are similar to many data breach laws at
interoperability as “the ability of health information the state level related to personally identifiable financial
systems to work together within and across organizational information (e.g., banking and credit card data). Under
boundaries in order to advance the effective delivery of the HITECH Act, unsecured PHI essentially means
health care for individuals and communities.” Without “unencrypted PHI.” In general, the Act requires that
interoperability, fundamental data and information, patients be notified of any unsecured breach. If a breach

impacts 500 patients or more, then HHS also must be may be excluded for 18 months. If a person had health
notified. Notification will trigger posting the breaching insurance coverage before enrolling in a new health plan,
entity’s name on HHS’ website. Under certain conditions, the exclusion period may be reduced by the number
local media also will need to be notified. Furthermore, of months a person was insured, as long as there were
notification is triggered whether the unsecured breach no significant breaks of 63 or more days of coverage.
occurred externally or internally. 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
Health Insurance Portability required to renew coverage to all groups regardless of
and Accountability Act the health status of any group member. Insurers may
not establish any rule that discriminates based on the
(HIPAA) health status of an individual or his or her dependent,
nor may they charge higher premiums or alter the level
Confidentiality of medical records has always been a of benefits. For those individuals with their own pri-
concern for health-care providers. Regardless of the vate health insurance plan, renewability is guaranteed.
medium of storage, confidentiality of data contained in Coverage cannot be terminated unless the premiums
the records will continue to be of utmost importance. are not paid, fraud is committed against an insurer, the
With the emphasis on interoperability and the criteria policy is terminated by the insured, the insured person
that define how EMR systems must be able to exchange moves outside the service area of a network plan, or the
confidential medical information securely, a discussion insurance is available only to members of that association
of the Health Insurance Portability and Accountability and membership in the association is ended. If the insur-
Act (HIPAA, or the Act) is warranted. ance company stops selling the policy, it must offer the
Enacted by Congress in 1996 to address a number insured another policy it sells in the same state. Further
of issues affecting national health care, HIPAA is a details may be found at http://healthcare.findlaw.com/
large and complex law continually subject to revi- patient-rights/hipaa-the-health-insurance-portability-
sions and amendments by legislative actions. The Act and-accountability-act.html.
establishes standards, and timetables for adoption of
the standards, for electronic transfers of health data, Electronic Health-Care Transactions
addressing growing public concern about privacy and Prior to implementation of HIPAA, it was estimated
security of personal health data. The primary goals of that about 400 different formats were being used to
the standards are (1) to combat fraud and abuse; (2) to process health claims online. Billing and other adminis-
make health insurance more affordable and accessible; trative procedures were inconsistent and varied among
(3) to simplify administration of health insurance claims health insurers, the government, and other entities. This
by requiring all entities to bill electronically using one made it difficult for providers, hospitals, health plans,
format; (4) to give patients more control of and access and health-care clearinghouses to process claims and
to their health-care information; and (5) to protect perform other transactions electronically. In an effort
medical records and individually identifiable medical to lower costs and improve efficiency, standards were
information from unauthorized use or disclosure, es- developed to simplify the administration of health in-
pecially in the burgeoning electronic age. surance claims by requiring common formats adopted
as national standards under HIPAA. The standards
Health Insurance Portability require that the same format is used to transmit the
The Health Insurance Portability provision of the Act following health-related information:
(Title I) improves the portability and continuity of
• Claims and equivalent encounter information
health insurance coverage for workers and their families
• Claim status
when they change or lose their jobs by limiting the re-
• Payment and remittance advice
strictions that a group health plan can place on benefits
• Enrollment and disenrollment in a plan
pertaining to a pre-existing condition. A pre-existing
• Eligibility for a plan
condition is a condition for which medical advice, diag-
• Premium payment
nosis, care, or treatment was recommended or received
• Referral certification and authorization
within the 6 months before the enrollment date for a
• Coordination of benefits
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 The Privacy Rule
enrollment period is considered a late enrollee, and Providers have an ethical and legal obligation to safe-
benefits for late enrollees with pre-existing conditions guard patients’ privacy. Because of the requirements of

transmitting sensitive health information electronically, business associate, there must be an agreement that
the Privacy Rule was written to protect the confidenti- the PHI will be handled according to federal and state
ality of individually identifiable health information. The privacy laws. Additionally, a CE may disclose PHI as
rule limits the use and disclosure of certain individually required by law, such as reporting child abuse to state
identifiable health information; gives patients the right child welfare agencies. Treatment covers a wide array of
to access their medical records; restricts most disclosures patient-related activities, including providing health care,
of health information to the minimum needed for coordinating services, referring patients, and consulting
the intended purpose; and establishes safeguards and among providers. Communication between CEs may
restrictions regarding the use and disclosure of records take place using any method, including oral, written,
for certain public responsibilities such as public health, electronic mail, or facsimile, as long as “reasonable and
research, and law enforcement. Under the rule, improper appropriate safeguards” are used to protect the information.
uses or disclosures may be subject to criminal or civil Payment includes activities relating to financial aspects
sanctions prescribed in HIPAA. Federal HIPAA regu- of health care. PHI can be used for billing and claim
lations do not pre-empt any state laws that are stronger processing to obtain reimbursement and for utilization
or more protective of consumers’ security and privacy. review. Health-care operations include a wide range of
administrative and management activities in which CEs
Protected Health Information engage. These include case management and patient care,
and Covered Entities risk management, legal services, credentialing, quality
PHI relates to the past, present, or future physical or assessments and outcomes development, guidelines and
mental health or condition of an individual; the provision protocol development, and training students. Sensitive
of health care to an individual; past, present, or future PHI includes information about certain conditions or
payment for the provision of health care to an individual; their associated treatment, such as HIV status, substance
and information that identifies or could reasonably be abuse, or mental health conditions. Use of PHI refers to
used to identify a protected individual. This information internal use by the CE; disclosure refers to sharing of PHI
may be oral, electronic, paper, or any other form. Individ- for external purposes. Sensitive PHI may not be disclosed
ually identifiable health information includes such data without a patient’s written authorization, except in certain
as name, Social Security number, patient identification circumstances, such as to a consultant who needs this
number (such as a medical record number), address, information to assist in the patient’s health care.
demographic data, or any other information that could Consent Versus Authorization
reasonably allow a person to be identified.
The Privacy Rule applies only to covered entities Consent must be obtained from the patient at the first
(CEs) that transmit medical information electronically. visit before any services are provided. Patients must sign
There are three categories of CEs: (1) health-care pro- a consent form stating that they have been notified
viders, such as doctors, clinics, psychologists, dentists, of the practice’s privacy policy, which explains that
chiropractors, nursing homes, and pharmacies; (2) health the practice may use and disclose PHI for treatment,
plans, including health maintenance organizations payment, and health-care operations. Consent needs to
(HMOs), health insurance companies, and government be obtained only once and is valid until revoked by the
programs that pay for health care, such as Medicare, patient in writing. In an emergency situation, treatment
Medicaid, and the military and veterans’ health-care may be rendered without consent, but consent should
programs; and (3) clearinghouses that electronically be obtained as soon as possible afterward.
transmit medical information, such as billing, claims, For all other uses and disclosures, unless required
enrollment, or eligibility verification. 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
Use and Disclosure of Protected authorization is needed to release PHI to life insurance
Health Information companies and patients’ legal counsel. A CE may not
HIPAA has very prescriptive language for the use and give or sell patients’ names for commercial or marketing
disclosure of PHI. A CE may use or disclose PHI purposes. For example, a CE may not give or sell names
without patient authorization for purposes of treatment, of allergy sufferers to pharmaceutical companies that
payment, or its health-care operations. This includes dis- market allergy products.
closures to its agents or to another CE, such as another
health-care provider. Agents are business associates who Individual Rights
perform a function for the CE, such as dictation, legal Patients have the right to review and obtain a copy of
services, billing, and accounting, and are not subject their medical records, except in certain circumstances.
to the Privacy Rule. When a CE discloses PHI to a Exceptions to the rule are psychotherapy notes, information

compiled for lawsuits, and information that, in the opin- health-care provider judges it to be in the patient’s best
ion of the health-care provider, may cause harm to the interest and as long as the patient has not restricted the
patient or another individual. A reasonable, cost-based release of information to that person.
fee may be charged to cover expenses for copying and
postage. If a medical summary of the record is requested, Minors
the fee should be agreed on beforehand. Patients also The Privacy Rule defers to state or other applicable
have the right to request an amendment or correction laws that address the ability of a parent or guardian
if they feel the record is inaccurate or incomplete and to obtain health information about a minor child. In
may submit a written supplement to be included in their most cases, the parent represents the child and has the
record. If the health-care provider declines the request, authority to make health-care decisions about the child;
the provider must do so in writing and allow the patient however, the Privacy Rule specifies three circumstances
to submit a statement of disagreement for inclusion when certain minors may obtain specified health care
in the record. However, the health-care provider must without parental consent:
allow the patient to submit a correction to be placed in
• When state or other law does not require the
the medical record. The CE also may include its own
consent of a parent before a minor can obtain a
rebuttal. A health-care provider may require a patient
particular health-care service, and when the mi-
to come into the office during normal business hours
nor consents to the health-care service. Example:
to access and inspect the record. The provider also may
A state law provides an adolescent the right to
arrange to have someone present who can answer any
obtain mental health treatment without the con-
patient questions or concerns.
sent of the parent, and the adolescent agrees to
Patients have a right to an accounting of certain PHI
such treatment without the parent’s consent.
disclosures by a CE. The CE must be able to report who
• When a court determines, or other law autho-
the recipient was, when the disclosure was made, and
rizes, someone other than the parent to make
for what purpose the disclosure was made. The maximal
treatment decisions for a minor. Example: A court
accounting disclosure period is the 6 years preceding
may grant authority to an adult other than the
the request. Exceptions to this rule include disclosures
parent to make health-care decisions for the mi-
for treatment, payment, or health-care operations; to
nor, such as a stepparent or guardian.
the individual or their representative; pursuant to an
• When a parent agrees to a confidential relation-
authorization; and for national security purposes.
ship between the minor and the physician. Exam-
CEs must take reasonable steps to ensure the con-
ple: A physician asks the parent of a 16-year-old if
fidentiality of communications with the patient. The
the physician can talk with the child confidentially
record should demonstrate how the patient would
about a medical condition and the parent agrees.
prefer to be contacted regarding PHI, including test
results, appointment reminders, or discussions regarding Even in these circumstances, the Privacy Rule defers
his or her medical care. The patient may request to be to state or other laws that require, permit, or prohibit
contacted at an alternative address or telephone number. the CE to disclose to a parent, or provide the parent
A health-care provider may share relevant information access to, a minor child’s PHI. When the laws are un-
with family, friends, or caregivers involved in a patient’s clear, a licensed health-care professional may exercise
health care as long as the patient does not object and professional judgment on whether to provide or deny
the provider feels it is in the patient’s best interest. In- parental access.
formation may not be disclosed to a person not involved When a health-care provider reasonably believes
in the patient’s health care, if disclosure is judged to be that disclosure of PHI to the personal representative
inappropriate by the provider, or if the patient requests who is authorized to make health-care decisions for
nondisclosure. When disclosing PHI, only the minimal an individual may not be in the patient’s best interest,
information needed by that particular person should the provider may choose not to disclose, especially in
be disclosed; for example, a caregiver needs to know situations in which abuse, neglect, and endangerment are
which medications are to be taken, what activity and suspected. For example, if a physician reasonably believes
dietary instructions are prescribed, and what changes in that disclosing information about an incompetent older
condition to report. Details about the patient’s diagnosis individual to the individual’s personal representative
and prognosis may not be necessary and should not be would endanger the patient, the Privacy Rule permits
disclosed unless requested by the patient or the patient’s the physician to decline to make such disclosures.
personal representative. A family member or friend
who is not involved in the patient’s care may be told of Notice of Privacy Practices
the patient’s condition—stable, guarded, critical—but Covered entities are required to develop a privacy pro-
additional information may not be disclosed unless the gram detailing how their practice complies with the

Table 1-2 Elements of a Privacy Policy on the Privacy Rule, to termination. If an employee
does not report observed or suspected violations to a
The policy should outline the following: supervisor or HIPAA officer, that employee may be
1. Describe how PHI is used and disclosed. subject to disciplinary action for failure to report.
2. State the CE’s duty to protect PHI, to provide a Although an individual may not sue anyone over a
notice of its privacy practices, and to abide by the HIPAA violation, a CE may be liable for civil penalties
terms in its notices.
at the state level. A CE’s failure to follow the rules
3. Describe patients’ rights to:
and standards of the HIPAA regulations can result in
• Inspect and copy their PHI
civil penalties of up to $100 per violation with a cap of
• Request a restriction of their PHI by stating the
specific restriction and to whom it applies $25,000 per year. Criminal penalties for violations by
• Request confidential communications from the individuals or CEs range from a $50,000 fine and up
CE by alternative means or at an alternative to 1 year of imprisonment for knowingly obtaining or
location disclosing PHI to a $250,000 fine and up to 10 years of
• Request an amendment to their PHI imprisonment if the offense is committed with intent
• Receive an accounting of certain disclosures to sell, transfer, or use PHI for commercial purposes,
the CE has made
personal gain, or malicious harm.
• Obtain a paper copy of the Notice of Patient
Privacy on their request
• Complain to the CE or to the secretary of Security Rule
HHS if they believe their privacy rights have been
violated Security standards were promulgated to protect elec-
4. Provide a point of contact for further information tronic health information systems from improper
and for submitting complaints to: access or alteration. The confidentiality, integrity,
• A practice’s designated HIPAA officer and availability of electronic PHI must be protected
• The secretary of HHS when it is stored, maintained, or transmitted. CEs are
required to develop and implement administrative,
physical, and technical safeguards to protect against
Privacy Rule. The notice must be provided to patients reasonably anticipated threats of loss or disclosure by
at or before their first encounter, or as soon as feasibly implementing appropriate policies and procedures.
possible in an emergency situation. It must be posted in Periodic security awareness and training of workforce
a clear and prominent location at the practice site and members is required. Administrative safeguards must
on its website, and a written copy should be furnished be in place to ensure the following:
to patients at their request. Written acknowledgment of • Properly authorized personnel have access only to
receipt of the Notice of Privacy Practices by the patient is the PHI they need to perform their job.
desirable; however, a patient may refuse to sign it (often • Prevention, detection, containment, and correc-
in the mistaken belief that signing it means the patient tion of security violations are undertaken, includ-
agrees with it), in which case the CE must document ing sanctions against an employee who violates
the reason for failure to obtain acknowledgment by the the privacy and security of PHI.
patient. Each practice should have a HIPAA privacy • A disaster recovery plan is outlined.
officer or a designated person who is knowledgeable • A process is in place to develop contracts with
in the standards and rules. A HIPAA attorney may be business associates that ensure they will safeguard
consulted in questionable matters when disclosure is a PHI appropriately.
concern. Table 1-2 shows the elements that should be
included in a privacy policy. Physical safeguards include measures that accomplish
the following:
Privacy Violations and Penalties • Limiting physical access to PHI systems while
CEs should have policies and procedures in place ensuring properly authorized access, such as
that describe sanctions for employees who commit keeping computers, printers, and fax machines
violations, such as accessing a medical record for any out of patient and high-traffic areas and installing
purpose outside of treatment, payment, or health-care locking doors and alarm systems.
operations; discussing PHI in public; failing to log off • Providing secure access to workstations, including
or leaving a computer monitor on and unsecured; or guidelines on use of home systems, laptops, cell
copying or compiling PHI with the intent to sell or phones, and other portable or handheld electronic
use it for personal or financial gain. Depending on the devices.
violation, disciplinary actions may range from a letter • Establishing procedures for receipt and removal
in the employee’s file, to requiring additional training of hardware and electronic media containing PHI.

Technical safeguards must be in place that protect and Practices may be audited for HIPAA compliance with
control access to PHI, such as the following: or without notice. New rules and policies are frequently
written, and CEs must be aware of and comply with
• Verifying identity of a person or entity
these. HHS and CMS websites should be monitored
• Allowing access only to people or software pro-
regularly for updates.
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 Summary
• Protecting PHI from improper modification or
The requirements for documentation of health-care ser-
destruction
vices have evolved over the past few decades. Health-care
• Preventing unauthorized access to PHI being
records are both medical and legal documents and serve
transmitted over an electronic communications
many purposes. The complexity of documentation reflects
network (e.g., the Internet)
the requirements of payers and regulatory agencies as
• Installing and regularly updating antivirus,
well as the need for clear and concise communication
anti-spyware, and firewall software
among members of the health-care team. Just as the
practice of medicine is both an art and a science, the
Summary of the Act practice of documentation is as well. Whether on paper or
A CE has the responsibility to develop and track a wide electronic based, records created by health-care providers
variety of privacy and security processes and establish must be timely and accurate and reflect good patient
policies and procedures to address all of the HIPAA care, support coding and billing, and meet regulatory
standards. Employees must undergo periodic training requirements. Completing the worksheets that follow
in privacy and security rules. Risk analysis, monitoring, will allow you to reinforce the content of this chapter.
and testing of information systems’ security are essen- And be sure to review Appendix A, the Document
tial to ensure the confidentiality and integrity of data. Library, for full case examples of patient documentation.

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”
Copyright © 2019 by F. A. Davis Company. All rights reserved. 15

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
16 Copyright © 2019 by F. A. Davis Company. All rights reserved.

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.

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.

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

Worksheet 1.2
Name
Abbreviations
These abbreviations were introduced in Chapter 1. Beside each, write the meaning as indicated by the context
of this chapter.
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

Chapter 2
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.
(Subjective, Objective, Assessment, and Plan; discussed

Introduction in Chapter 3) notes and admission H&Ps (as discussed
in Chapter 10), are variations of the comprehensive H&P.
The comprehensive history and physical examination
Multiple providers are likely to read this document and
(complete H&P or H&P) is the vehicle used to doc-
use it to guide their management of the patient; this
ument not only the patient’s medical history but also
is one reason it is so important that the documented
the physical examination findings, diagnoses or medical
H&P accurately reflects the patient’s past and current
problems, diagnostic studies to be performed, and ini-
health status and even documents anticipated problems.
tial plan of care implemented to address any problems
Providers in different medical disciplines usually tailor
identified. Although obtaining a thorough history and
the H&P to their specialty. An H&P conducted and
performing a detailed physical examination are critically
documented by a cardiologist, for example, will differ
important, the documentation of the H&P is equally
from an H&P completed by an orthopedist.
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 Components of
important findings—may lead to inadequate care of the
patient. Failure to document the comprehensive H&P
a Comprehensive History
adequately could have the same result. and Physical Examination
Typically, the comprehensive H&P is obtained when
a provider sees a patient for the first time in a general The components of a comprehensive H&P are shown
medical setting or when a patient is admitted to the in Table 2-1. The discussion in this chapter is geared to
hospital. One exception is when the patient presents adult patients. Documentation of the newborn physical
with an emergent complaint and initiating treatment examination is presented in Chapter 4, pediatric and
is a higher priority than obtaining a detailed history or adolescent patients are presented in Chapter 5, and
performing a thorough physical examination. Almost older adults in Chapter 7. Specific information that
all other types of documentation, including SOAP should be documented in each section follows.
23

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

HISTORY • Neurological
Identification • Psychiatric
Chief Complaint (CC) • Endocrine
History of the Present Illness (HPI) • Hematologic/lymphatic
• Allergic/immunologic
• Location
• Quality PHYSICAL EXAMINATION
• Severity • General
• Duration • Vital signs
• Timing • Skin
• Context • Head, eyes, ears, nose, throat (HEENT)
• Modifying factors • Neck
• Associated signs and symptoms • Respiratory
Past Medical History (PMH) • Cardiovascular
• Current and past medical problems unrelated to the CC • Breast
• Surgeries and other hospitalizations • Abdomen
• Current medications, including prescription and over the • Male genitalia or gynecological (breast examination
counter sometimes documented here)
• Drug allergies, including how manifested • Rectal
• Health maintenance and immunizations • Musculoskeletal
• Neurological
Family History (FH)
• Mental status
• Age and status of blood relatives • Cranial nerves
• Medical problems of blood relatives • Motor
Social History (SH) • Cerebellum
• Patient profile • Sensory
• Lifestyle risk factors • Reflexes
• Employment LABORATORY DATA
• Education • Results of laboratory tests, radiographs, etc.
• Religion, beliefs
• Cultural history PROBLEM LIST, ASSESSMENTS,
• Support system AND DIFFERENTIAL DIAGNOSES
• Stressors • Most severe to least severe initially
Review of Systems (ROS) • Other problems added chronologically
• Indicate if active or inactive
• General
• Eyes TREATMENT PLAN
• Ears, nose, and throat/mouth • Additional laboratory and diagnostic tests
• Cardiovascular • Medical treatment
• Respiratory • Consults
• Gastrointestinal • Disposition, such as admit, follow as outpatient, etc.
• Genitourinary
• Musculoskeletal
1
History and Physical Examination headings used by CMS 1997 Guidelines of Documentation for Evaluation and Management.
History provide historical information accurately. If you use an

interpreter when performing the H&P, document this
Identification
as well (Fig. 2-1).
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 Chief Complaint
name, date of birth, age, race, and gender. In a hospital Document the current problem, or chief complaint
setting, you would include that information as well as (CC), for which the patient is seeking care. This is
the medical record number, attending or referring phy- best stated in the patient’s own words, identified by
sician, and consulting physicians. You should document quotation marks. At times, a patient may present in an
the patient’s reliability, that is, the patient’s ability to outpatient setting without a specific complaint, such as

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.
presenting to establish care or for an annual physical. and immunizations. Using subheadings within the
Try to avoid vague terms, such as checkup, and do not PMH, as shown in Table 2-3, makes it easier to locate
document “no problems” in the CC. information and identify the change from one topic
to another.
History of the Present Illness or History If the patient has multiple medical problems, it
of the Chief Complaint may be helpful to document them as an enumerated
list rather than in paragraph format. If the patient has
The history of the present illness (HPI) is a chrono- had any surgery or hospitalizations for major trauma or
logical description of the development of the patient’s other reasons, be sure to include the type of operation
present illness from the first sign or symptom of the and date of the surgery; if known, you can include the
presenting problems. The Centers for Medicare and name of the doctor who ISBN performed the surgery.
Medicaid Services (CMS) published the 1995 and Author
You Sullivan
should document a6662
#
medication list
Author's review
as partOKof the
(if needed)
1997 Documentation Guidelines for Evaluation and PMH. Fig. This#
includes both prescription medications and
Document name
Correx
Management of Services, identifying these elements of F02_01

over-the-counter
6662_C_F02_01.eps
products, such as herbalInitials supplements,
Date
the HPI: location, quality, severity, duration, timing, vitamins,

Artist
minerals, andCheck
Date
03/27/18
dietary supplements. Be sure
AB/CO
context, modifying factors, and associated signs and to include the name of the
if revision X Editor's review
medication, the dose,
2nd color OK howCorrex
symptoms. Several mnemonics may be used to help B/W X
frequently it is
4/C
taken, and
2/C
ideally,PMS
why the patient takes
you remember the elements of the HPI that should Final Size (Width X Depth in Picas)
the medication. Review the list of medications Initials
Date
with the
39p10 x 15p10
be elicited; these are shown in Table 2-2. A word of patient at every visit to ensure accuracy.
caution: These mnemonics are helpful when the patient It is extremely important to document any drug
presents with a complaint of pain, but they may not allergies the patient has. You may document food
be as helpful when a patient presents with a vague allergies in this section also. You should document the
complaint like fatigue or when the patient presents specific reaction the patient experiences when the food
for monitoring of a chronic condition. Your approach or drug is ingested. In most settings, there will be a
to obtaining and documenting the HPI will differ in specific way to indicate a drug allergy, such as a special
these situations. sticker affixed to the front of the patient’s chart, so that
it is not overlooked. In an electronic medical record
Past Medical History (EMR), the text may be a different color or there may
Use the past medical history (PMH) section to document be a special tab or menu bar to highlight any allergies.
the patient’s past and current health. Document when It is critically important to inquire specifically about
each condition was diagnosed, and indicate its present and document an allergy to latex. A patient with a
status, such as stable, uncontrolled, or resolved. You may latex allergy will need special equipment. You should
subdivide information in the PMH into past medical document environmental allergies, such as an allergy
history, past surgical history or other hospitalizations, to cats that results in allergic rhinitis, in the PMH.
medications, drug allergies, and health maintenance If the patient is treated regularly for allergy-related

Table 2-2 History of Present Illness Table 2-3 Subheadings Used for Past Medical
Mnemonics History
Mnemonic Explanation • Past Medical History
PQRST P—palliative or provocative factors • Medical
Q—quality of pain • Surgical/hospitalizations
R—region affected • Medications
S—severity of pain • Allergies
• Health maintenance/immunizations
T—timing
LOCATES L—location
O—onset
C—character and gender. Chapters 5, 6, and 7 discuss documenta-
A—associated signs and symptoms tion of health maintenance activities and immuniza-
T—timing tions in the pediatric, adult, and older adult patient,
E—exacerbating/relieving factors respectively.
S—severity
OLD CHARTS O—onset Family History
L—location Typically, you should document the medical history
D—duration of first-degree relatives, that is, the family history
CH—character (FH) for parents, grandparents, siblings, and children.
A—alleviating/aggravating Remember that a spouse’s medical history is not
R—radiation considered part of the patient’s FH, although it may
T—temporal pattern be applicable in situations in which a couple presents
S—symptoms associated because of infertility or genetic counseling. Document
COLDERAS C—character the age and status (living, deceased, health status) of
O—onset the first-degree relatives. If those relatives are deceased,
L—location include the age at time of death and cause of death. If
D—duration the relatives are still living, document their current age
E—exacerbating factors and medical conditions, paying particular attention to
R—relieving factors those conditions that have a familial tendency such as
A—associated signs and symptoms cardiovascular disease, diabetes, and certain cancers,
S—severity osteoporosis, and sleep apnea. Also determine whether
LIQORAAA L—location any first-degree relatives have or had the condition with
I—intensity which the patient is presenting. In addition to medical
Q—quality conditions, inquire about any substance abuse, addic-
O—onset tions, depression, or other mental health conditions of
R—radiation family members.
A—associated signs and symptoms
A—alleviating factors Social History
A—aggravating factors One of the main goals of documenting the social
QFLORIDAA Q—quality history (SH) of the patient is to identify factors out-
F—frequency side of past or current medical conditions that may
L—location influence the patient’s overall health or behaviors that
O—onset create risk factors for specific conditions. These risk
R—radiation factors include use of tobacco, alcohol, and drugs.
I—intensity If these risk factors are present, document quantity
D—duration of use and how long the use has occurred. Smoking
A—alleviating/aggravating history should include number of packs per day and
A—associated signs and symptoms 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
conditions, document these conditions under the use with the addition of how long it has been since
heading of Medical Conditions rather than Allergies. the patient quit. Avoid ambiguous terms such as
The health maintenance and immunization section social drinker that do not assist you or other readers in
of the PMH will vary according to the patient’s age determining whether there is a risk factor associated

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

Communication Nutrition
• Is a translator needed? • Specific food rituals
• What is your primary oral language? • Specific food avoidances
• What is your primary written language? • Major foods
• Preparation practices
Beliefs Affecting Health and Illness
Special Events
• What do you think caused your illness or condition?
• How does it affect your life? • Prenatal care
• Have you seen anyone else about this problem? • Death and burial rituals
• If yes, who? • Beliefs of afterlife
• Have you used any home remedies for your problem? • Willing to accept blood transfusions?
• If yes, what? • Willing to accept organ transplantation?
• Are you willing to take prescription medications? • Organ, blood, or tissue donor?
• Are you willing to use alternative therapies, such as
herbal medicine? Spirituality
• Dominant religion
Family
• Active participant?
• Definition of family • Prayer and meditation
• Roles within family • Special activities
• Who has authority for decision-making related to your • Relationship between spiritual beliefs and health
health care? practices
Symbols Taboos
• Special clothing • Describe any taboos that would affect health care
• Ritualistic and religious articles
with substance use. Typically, the use of illegal sub- special events, spirituality, and taboos. Table 2-4 shows
stances is documented as drug use, but also you should questions that you can ask as part of the religious and
determine whether the patient is taking substances cultural history.
prescribed for someone else or misusing prescription Document nutritional information in terms of type of
medication. If a risk factor is identified, be sure to diet the patient follows, caffeine intake, and food allergies
include it in the problem list and assessment and or avoidances. If there are questions or concerns about a
plan. Age-specific SH is discussed in other chapters. patient’s diet, it may be helpful to record a “typical day”
Information about the patient’s sexual orientation, or “last 24 hours” of food intake. Sedentary lifestyle is
gender identification, marital status, and number of a risk factor for certain diseases, so document whether
children is included. Documentation of the patient’s the patient exercises. If the patient exercises, include
past and current employment may help identify the type, frequency, and duration of exercise.
potential occupational hazards. Include any military One basic consideration of a patient’s ability to ac-
service and where stationed (stateside or overseas) as cess health care is whether the patient has health-care
well as any possible exposures. If the patient has lived insurance or some other form of payment, such as
or traveled abroad, document locations and potential Social Security or workers’ compensation. Although
exposures, if any. It is important to document the pa- financial records generally should be kept separate from
tient’s educational level and ability to read and write. the medical records, you should document whether the
If the patient speaks more than one language, you patient is insured or uninsured. If uninsured, information
should document which language the patient prefers. about income or ability to self-pay becomes essential.
Religion and religious and cultural beliefs may The provision or lack of insurance will guide many
have an impact on a patient’s overall health. It can health-care choices, especially related to prescribing
be difficult to determine the difference between a re- medications. Using generic instead of brand-name
ligious belief and a cultural belief, although typically medications will result in cost savings for the patient
it is not necessary to do so. Specific documentation and is often medically neutral, meaning the patient
of the religious and cultural history includes beliefs should get the same benefit from generic as from
related to health and illness, family, symbols, nutrition, brand-name medications.

MEDICOLEGAL ALERT ! Specific symptoms include weight loss, weight

gain, fatigue, weakness, fever, chills, and night
Documenting that you have counseled the patient on sweats.
the risks of negative health habits and the management 2. Eyes: change in vision, date of last visual
of chronic disease is an important part of the manage- examination, glasses or contact lenses, history
ment of medicolegal risk. Providers have been sued for of eye surgery, eye pain, photophobia, diplopia,
not providing patient education and counseling. One spots or floaters, discharge, excessive tearing,
such case involved a 33-year-old woman who was itching, cataracts, or glaucoma.
obese and hypertensive and smoked. She had frequent 3. Ears, nose, and mouth/throat (ENT):
visits to the clinic for various complaints. Routine screen- a. Ears: change in or loss of hearing, date of last
ing tests revealed marked hypercholesterolemia and auditory evaluation, hearing aids, history of ear
an abnormal ratio of high-density lipoprotein (HDL) surgery, ear pain, tinnitus, drainage from the
to low-density lipoprotein (LDL). The health-care pro- ear, history of ear infections.
vider never counseled the patient regarding her risk for b. Nose: changes in or loss of sense of smell,
coronary artery disease. Several years later, the patient epistaxis, obstruction, polyps, rhinorrhea,
presented to an emergency room with crushing chest itching, sneezing, sinus problems.
pain that radiated to her arms and neck. The diagnosis c. Mouth/throat: date of last dental examina-
of myocardial infarction was confirmed, but by the time tion, ulcerations or other lesions of tongue or
the diagnosis was made, the window of opportunity for mucosa, bleeding gums, gingivitis, dentures or
thrombolytic therapy had closed. The patient sued the any dental appliances.
clinic and the health-care provider for malpractice. The 4. Cardiovascular (CV): chest pain, orthopnea,
health-care provider was found negligent for not educat- murmurs, palpitations, arrhythmias, dyspnea
ing and counseling the patient about her risk factors for on exertion, paroxysmal nocturnal dyspnea,
developing heart disease. peripheral edema, claudication, date of last
electrocardiogram or other cardiovascular studies.
5. Respiratory: dyspnea, cough, amount and color
Review of Systems of sputum, hemoptysis, history of pneumonia,
date of last chest radiograph, date and result of
The review of systems (ROS) is an inventory of specific last tuberculosis testing.
body systems designed to document any symptoms the 6. Gastrointestinal (GI): abdominal pain;
patient may be experiencing or has experienced. Typically, dysphagia; heartburn; nausea; vomiting; usual
you should document both positive symptoms (those bowel habits and any change in bowel habits;
the patient has experienced) and negative symptoms use of aids such as fiber, laxatives, or stool soft-
(those the patient denies having experienced). A positive eners; melena; hematochezia; hematemesis;
response from a patient about any symptom should hemorrhoids; jaundice.
prompt you to explore all elements of that symptom 7. Genitourinary (GU): frequency, urgency,
just as you would for the HPI (location, quality, severity, dysuria, hematuria, polyuria, incontinence, sex-
duration, timing, context, modifying factors, and associ- ual orientation, number of partners, history of
ated signs and symptoms). Rather than asking whether sexually transmitted infections, infertility.
the patient has ever experienced any of the symptoms a. Males: hesitancy, change in urine stream,
listed, it is appropriate to limit the review to a specific nocturia, penile discharge, erectile dysfunction,
time frame. That time frame might change depending date of last testicular examination, date of last
on the patient’s CC and HPI; if you are seeing a patient prostate examination, date and result of last
for the first time, it is usually sufficient to ask about the prostate-specific antigen (PSA) test.
past year. If the patient has been seen before, ask about b. Females: GU symptoms as described
the time frame since the previous visit. previously and gynecological symptoms;
Consistent with the 1995 and 1997 CMS guidelines, age at menarche; gravida, para, abortions;
14 systems are identified, and specific symptoms that frequency, duration, and flow of menstrual
should be explored in each system are included here. periods; date of last menstrual period;
How many symptoms are explored within each system dysmenorrhea; type of contraception used;
is up to you as indicated by the patient’s presenting ability to achieve orgasm; dyspareunia;
complaint. vaginal dryness, menopause; breast lesions,
1. Constitutional: these symptoms do not fit spe- date and type of last breast imaging; date and
cifically with one system but often affect the result of last Papanicolaou smear, date of last
general well-being or overall status of a patient. pelvic examination.

8. Musculoskeletal (MSK): arthralgias, arthritis, Table 2-5 Order in Which to Document

gout, joint swelling, trauma, limitations in range Physical Examination
of motion (ROM), back pain. (Note that numb-
ness, tingling, and weakness are typically not • General assessment
included in musculoskeletal but in neurological • Vital signs: temperature, pulse, respiration, blood
system.) pressure, height, weight, body mass index (BMI)
• Skin
9. Integumentary: rashes, pruritus, bruising, dry-
• HEENT
ness, skin cancer or other lesions. • Neck
10. Neurological: syncope, seizures, numbness, tin- • Respiratory
gling, weakness, gait disturbances, coordination • Cardiovascular
problems, altered sensation, alteration in mem- • Abdomen
ory, difficulty concentrating, headaches, head • Genitourinary or gynecological
trauma, or brain injury. (Headache, head trauma, • Musculoskeletal
or brain injury may also be listed under head, as • Neurological
part of Head, Eyes, Ears, Nose, Mouth/Throat,
or HEENT.)
11. Psychiatric: emotional disturbances, sleep distur-
Generally, the examination will proceed in a head-to-toe
bances, substance abuse disorders, hallucinations,
fashion. In some instances, it may be necessary to deviate
illusions, delusions, affective or personality disor-
from this order, such as performing an invasive com-
ders, nervousness or irritability, suicidal ideation
ponent at the end of the examination or examining an
or past suicide attempts.
area of pain last. Regardless of the order in which the
12. Endocrine: polyuria, polydipsia, polyphagia, tem-
examination is performed, documentation of the physical
perature intolerance, hormone therapy, changes
examination should follow the order that follows and
in hair or skin texture.
in Table 2-5. Consult other textbooks for instruction
13. Hematologic/lymphatic: easy bruising, bleeding
on how to perform the physical examination and for a
tendency, anemia, blood transfusions, thrombo-
discussion on the importance of any findings; here the
embolic disorders, lymphadenopathy.
emphasis is on the documentation of a comprehensive
14. Allergic/immunologic: allergic rhinitis, asthma,
physical examination.
atopy, food allergies, immunotherapy, frequent or
chronic infections, HIV status; if HIV positive, • General: age, race, gender, general appearance.
date and result of last CD4 count. Documentation of general appearance could in-
clude alertness, orientation, mood, affect, gait, how
You may use standard forms or templates for gathering
a patient sits on the examination table or chair,
much of the history information, and this is certainly
grooming, and the patient’s reliability to provide an
an acceptable, time-saving practice. However, you have
adequate history. Document whether the patient
an obligation to review and verify the information that
is in any distress or whether the patient appears
the patient provides. Staff members may use the forms
markedly older or younger than the stated age.
to enter information into an EMR. The original paper
• Vital signs: temperature, blood pressure, pulse,
forms should be scanned into the EMR.
respiratory rate, height, weight, and body mass
index (BMI).
Physical Examination • Skin: presence and description of any lesions,
The rationale for physical examination rests on a basic scars, tattoos, moles, texture, turgor, temperature;
assumption that there is such a thing as normality of hair texture, distribution pattern; nail texture, nail
bodily structure and function corresponding to a state of base angle, ridging, pitting.
health and that departures from this norm consistently • HEENT:
result from or correlate with specific abnormal states or • Head (including face): size and contour of head,
disease. It is helpful to think about a “range of normal” symmetry of facial features, characteristic facies,
when it comes to physical examination findings, rather tenderness or bruits of temporal arteries.
than a single “normal” for every part of the examina- • Eyes: conjunctivae; sclera; lids; pupil size, shape,
tion. The physical examination may confirm or refute and reactivity; extraocular movement (EOM);
a diagnosis suspected from the history, and by adding nystagmus; visual acuity. Ophthalmoscopic
this information to the database, you will be able to findings of cornea, lens, retina, red reflex, optic
construct a more accurate problem list. Like the history, disc color and size, cupping, spontaneous venous
the physical examination is structured to record both pulsations, hemorrhages, exudates, nicking, arte-
positive and negative findings in detail. riovenous crossings.

Table 2-6 Cranial Nerves and Their Function

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
• Ears: integrity, color, landmarks, and mobility of Table 2-7 Muscle Strength Grading
the tympanic membranes; tenderness, discharge,
external canal, tenderness of auricles, nodules. Grade Meaning
• Nose: symmetry, alignment of septum, nasal 0 No motion or muscular contraction detected
patency, appearance of turbinates, presence of 1 Barely detectable motion
discharge, polyps, palpation of frontal and max- 2 Active motion with gravity eliminated
illary sinuses. 3 Active motion against gravity
• Mouth/throat: lips, teeth, gums, tongue, buccal 4 Active motion against some resistance
mucosa, tonsillar size, exudate, erythema. 5 Active motion against full resistance
• Neck: ROM, cervical and clavicular lymph nodes,
thyroid examination, position and mobility of the
trachea.
• Respiratory: effort of breathing, breath sounds, mobility of the cervix; cervical motion tender-
adventitious sounds, chest wall expansion, sym- ness, uterine or ovarian enlargement, masses,
metry of breathing, diaphragmatic excursion. tenderness, adnexal masses or tenderness.
• Cardiovascular: heart sounds, murmurs or extra • Rectal: hemorrhoids, fissures, sphincter tone,
sounds, rhythm, point of maximal impulse, masses, rectocele; if stool is present, color and
peripheral edema, central and peripheral pulses, consistency of stool, test stool for occult blood;
varicosities, venous hums, bruits. prostate examination for males, noting size,
• Breast: symmetry, inspection for dimpling of skin, uniformity, nodules, tenderness.
nipple discharge, palpation for tenderness, cyst or • Musculoskeletal: symmetry of upper and lower ex-
masses, axillary nodes, gynecomastia in males. tremities, ROM of joints, joint swelling, redness or
• Abdomen: shape (flat, scaphoid, distended, obese), tenderness, amputations; inspection and palpation
bowel sounds, masses, organomegaly, tenderness, of spine for kyphosis, lordosis, scoliosis, musculature,
inguinal nodes. range of motion, muscles for spasm, or tenderness.
• Male genitalia or gynecological (breast • Neurological:
examination sometimes documented here). • Mental status: level of alertness; orientation to
• Male genitalia: hair distribution, nits, testes, person, time, place, and circumstances; psychiat-
scrotum, penis, circumcised or uncircumcised, ric mental status or mini–mental state examina-
varicocele, masses, tenderness. tions if indicated.
• Gynecological: External—inspection of the • Cranial nerves: see Table 2-6 for details of the
perineum for lesions, nits, hair distribution, areas 12 cranial nerves and their functions.
of swelling or tenderness, labia and labial folds, • Motor: strength testing of upper and lower
Skenes and Bartholin glands, vaginal introitus; extremity muscle groups proximally and dis-
noting any discharge or cystocele if present. tally graded on a scale of 0 to 5 as shown in
Internal—inspect vaginal walls and cervix for Table 2-7.
color, discharge, lesions, bleeding, atrophy; • Cerebellum: Romberg test, heel to shin, finger
inspect cervical os for size and shape; bimanual to nose, heel-and-toe walking, rapid alternating
examination for size, shape, consistency and movements.

• Sensory: sharp/dull discrimination, tempera- Table 2-8 Grading Reflexes

ture, stereognosis, graphesthesia, vibration,
proprioception. Grade Meaning
• Reflexes: brachioradialis, biceps, triceps, quadri- 0 Absent
ceps (knee), and ankle graded on a scale of 0 to 1+ Decreased or less than normal
4+ as shown in Table 2-8. 2+ Normal or average
3+ Brisker than usual
Based on your reading, complete the application exer-
4+ Hyperactive with clonus
cises that follow.

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.
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).

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.
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).

Laboratory and Diagnostic Studies 2. Diabetes, not well controlled: review of home
glucose monitoring logs shows fasting range of
Following documentation of the H&P, document the
150 to 180.
results of any studies, such as laboratory tests, radio-
3. New-onset left leg swelling: no trauma, no er y-
graphs, or other imaging studies. All results should be
thema. Pulses are present. Concern for deep vein
specifically recorded. For instance, rather than docu-
thrombosis (DVT).
menting, “the complete blood count (CBC) is normal,”
Plan:
document the value for each part of the CBC. This is
1. Stop ACE inhibitor. Will switch to losar tan 50 mg
done for several reasons. First, it presents the actual
once daily.
values and allows readers of the H&P to formulate
2. Check HgbA1C; continue metformin, add
their own conclusions regarding the meaning of the
g lipizide 5 mg twice daily. Continue home glucose
values. Second, it documents the baseline values that
monitoring.
the patient has as a reference point. Third, it saves time
3. Left leg Doppler flow study.
for other readers to have the values listed rather than
Return to clinic in 2 weeks.
having to look them up.
Assessment/Plan:
Problem List, Assessment, and 1. Cough: nonproductive and no signs or symptoms
of infectious process. Recently star ted an ACE in-
Differential Diagnosis hibitor, so may be side effect of medication. Stop
Once you have documented all the elements of ACE inhibitor. Will switch to losar tan 50 mg once
the H&P and results of diagnostic studies, you can daily.
evaluate all the information to identify the patient’s 2. Diabetes, not well controlled: review of home glu-
problems. Use a numbered list that includes the date cose monitoring logs shows fasting range of 150
of onset and whether a particular problem is active to 180. Check HgbA1C; continue metformin, add
or inactive. List the most severe problems first. After glipizide 5 mg twice daily. Continue home glucose
the initial list is generated, new problems are listed monitoring.
chronologically. 3. New-onset left leg swelling: no trauma, no
Make an assessment of each current problem. This er ythema. Pulses are present. Concern for DVT;
entails a brief evaluation of the problem with differential left leg Doppler flow study.
diagnosis. This is a very important component of the Return to clinic in 2 weeks.
comprehensive H&P because it demonstrates your
judgment and documents the medical decision-making
that you considered regarding each problem. Sample Comprehensive History and
Plan of Care Physical Examination
A sample comprehensive H&P for Mr. William Jensen
Document any additional studies or workup needed,
is shown in Figure 2-2. Mr. Jensen is a new patient to
referrals or consultations needed, pharmacological man-
the practice of Dr. Vernon Scott, and you will follow
agement, nonpharmacological or other management,
his medical course through the documentation of his
patient education, and disposition such as “return to
encounters with a surgeon, his admission to the hospital,
clinic” or “admit to the hospital.”
surgery, hospital course, and discharge. In addition to
There are different ways that you can document the
documentation related to Mr. Jensen, you will have the
assessment and plan. Sometimes you will see assess-
opportunity to evaluate other documentation.
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 Summary
is used depends largely on health-care provider pref-
The comprehensive history and physical examination
erence and whether documentation is paper-based
(H&P) is one of the most important documents in
or EMR-based.
the patient’s entire medical record. The H&P will vary
somewhat in content at different ages and stages of life
EXAMPLE 2.1
and among different medical disciplines as discussed
Assessment: in other chapters; however, the structure of the H&P
1. Cough: nonproductive and no signs or symptoms is typically the same. Typically, you will complete the
of infectious process. Recently star ted an comprehensive H&P at an initial patient visit in the
a ngiotensin-conver ting enzyme (ACE) inhibitor, ambulatory setting, and documentation of subsequent
so may be side effect of medication. visits will not be as detailed. The goal of the H&P is to

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.
(Continued)
Author ISBN # Author's review

Sullivan 6662 (if needed)
OK Correx
Fig. # Document name
F02_02_p1 6662_C_F02_02_p1.eps Date
Initials
Artist Date
03/27/18
AB/CO Editor's review
Check if revision X
2nd color OK Correx
B/W 4/C 2/C X PMS
Final Size (Width X Depth in Picas) Date
Initials
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.
(Continued)
Copyright © 2019 by F. A. Davis

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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
Figure 2-2 Sample comprehensive history and physical examination.
elicit detailed information about the patient’s medical of life. Completing the worksheets that follow will help
history in order to identify risk factors, guide decisions reinforce the material presented in this chapter. And be
for health maintenance, and to identify and treat con- sure to review Appendix A, the Document Library, for
ditions that will impact the patient’s health and quality full case examples of patient documentation.

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Worksheet 2.1
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?

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.
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
7\OHU0DUWLQ06,,,
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38 Copyright © 2019 by F. A. Davis Company. Author's
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rights reserved.
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Worksheet 2.2
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:

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?

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.

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.
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.
6X]HWWH%DUQHV13
Author ISBN #
42 Copyright © 2019 by F. A. Davis Company. Author's
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Worksheet 2.3
Name
Abbreviations
These abbreviations were introduced in Chapter 2. Beside each, write the meaning as indicated by the content
of this chapter.
ACE SOAP
CBC BMI
CMS CC
CV DVT
EMR EOM
ENT GI
FH H&P
GU HEENT
HDL MSK
HPI PSA
LDL ROS
PMH SH
ROM

Chapter 3
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 Subjective
Although it is necessary to perform and document a It is beyond the scope of this book to address interviewing
comprehensive history and physical examination (H&P) techniques and interpersonal skills; you should employ
at the beginning of the patient–provider relationship, it your best communication techniques when interviewing
is unnecessary and too time consuming to document that the patient and obtaining the history that will make
level of detail at subsequent visits. It is unlikely that much up the Subjective portion of the SOAP note. (Several
of the history information would change if the patient reference texts that deal with medical interviewing
has frequent visits for monitoring chronic conditions. are listed in the bibliography.) Although all parts of
Also, the comprehensive H&P may be documented at a SOAP note are important, your ability to take and
times when the patient does not present with a specific record an accurate medical history is one of the most
complaint. At other times, visits are problem focused, important tasks to be mastered in medicine. In 1947,
either for monitoring of chronic conditions or for Platt claimed that, in most cases, the diagnosis can be
evaluation of a new problem. One way to document made with the history alone. In 1975, Hampton and
problem-focused visits is with a SOAP note. SOAP colleagues attempted to evaluate the relative contribu-
stands for Subjective, Objective, Assessment, and Plan. tions of history taking, the physical examination, and
The SOAP format is used in many different practice laboratory tests in making medical diagnoses. Nearly 20
settings. It is important to understand that sections years later, Peterson and colleagues undertook a study
of the SOAP note are interrelated. The completeness to quantitate the relative contributions of the history,
and accuracy of the history (subjective information) physical examination, and laboratory investigation in
will help guide what you look for when performing making medical diagnoses. They found that history
a problem-specific physical examination (objective taking led to the final diagnosis in 61 of 80 patients, or
information) and formulating a list of possible causes, 76% of encounters. More recent studies have validated
also known as differential diagnoses (DDX). Together, these findings. With all the technological advances and
the subjective and objective information should lead the availability of diagnostic testing, the temptation is
you to, and should support, the assessment or most to minimize or abbreviate the history taking, but doing
likely diagnosis. Once you have made an assessment, so may jeopardize your ability to reach an accurate
you can establish a plan of care. diagnosis. Obtaining an adequate history often will
45

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.
take the most time during a patient encounter, but Subjective information is what the “subject” or patient tells
this is time well spent. Likewise, the attention given to you. As discussed in Chapter 2, the chief complaint (CC)
documenting the Subjective portion of a SOAP note is best recorded in the patient’s own words, but, in some
is equally important. electronic medical records (EMRs), you may have to choose
The elements of the comprehensive H&P that are the CC from a list, as shown in Figure 3-1. Sometimes,
identified as subjective information are as follows: subjective information is obtained
Author ISBN # from someoneAuthor's review other than
• Chief complaint (CC) the patient.
Fig. #
A spouse or family
Document name
member, a caregiver, OK
and
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• History of present illness (HPI) members of the health-care

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• Problem-focused or pertinent past medical information.

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istory (PMH) prior medical r ecords. If someone otherEditor's
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• Problem-focused or pertinent family history (FH) providesB /the
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• Problem-focused or pertinent social history (SH) and his Final

or her relationship
Size (Width to the patient.
X Depth in Picas) Date
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• Any specialized history related to the chief On occasion,
41p0 x 32p9 you might want to use quotation marks
complaint (for instance, obstetrical and gyneco- to identify information as a direct quote from the patient
logical history for a female patient who presents and to indicate that you have recorded the patient’s exact
with irregular menses) words. This is particularly so when recording the CC if
• Problem-focused or pertinent review of systems the patient is describing something (such as pain) or if the
(ROS) patient does not answer a question to your satisfaction.

Chapter 3 SOAP Notes | 47
For instance, when asked if she takes any medication, eventually lead to the most likely diagnosis. Try to anticipate
a patient responds, “Yes, I take a little red pill for my what information other readers want to know, such as
blood pressure.” You could guess what that little red pill the presence or absence of certain findings, and be sure
may be, but for the sake of accuracy, it would be better that the information is included in your documentation.
to document this information using the patient’s own For example, if an 18-month-old child presents with a
words (patient takes “a little red pill” for hypertension). history of fever and a rash, and the parent states that the
The use of quotation marks lets other readers know that child is inconsolable, the diagnosis of meningitis should
the information within the marks is not your paraphrase come to mind. Your documentation should reflect that you
or restatement of something the patient told you but considered this diagnosis; therefore, it should include the
the actual words from the patient. Notice that the word presence or absence of symptoms that are associated with
“hypertension” was substituted for “blood pressure.” It meningitis. Lethargy is one such symptom; therefore, if
is acceptable to do this because the patient is stating a the child is attentive and looking around the room and
fact and you are translating the lay term into an accepted interactive with his environment, these are pertinent
and more specific medical term that will have consistent negatives in the child’s history that lead you away from
meaning to others who will read the note. the diagnosis of meningitis or make it less likely.
One of the most challenging aspects of documenting
the subjective information is determining what elements Analyzing Documentation
of the history are pertinent to the presenting complaint. There are at least two ways to develop documentation
It takes years of practicing medicine to understand the skills: (1) practice, practice, and practice, and (2) crit-
importance of certain associated signs and symptoms ically analyze documentation. This text gives you the
and how they relate to the CC. Many conditions have opportunity to do both. Read the subjective information
a certain pattern of presentation. A man having a myo- documented in the following two examples, and then
cardial infarction is likely to present with chest pain or answer the questions.
pressure, sometimes radiating to the neck, jaw, or arm;
nausea, dyspnea, and diaphoresis are often part of the EXAMPLE 3.1
symptom complex of infarction. Not only should you
ask about all these signs and symptoms as you gather CC: “my left knee hur ts”
the medical history, but also you should document the S: This 42-year-old man presents with complaint of left
absence or presence of each of these signs and symptoms. knee pain. He injured his knee while playing softball. His
Some findings from the history will support or suggest pain has gradually worsened over the past week. He
one diagnosis more than another. These findings are has not noticed any swelling. He denies any numbness
“pertinent positives” because their presence is pertinent below the knee. He has not had any prior knee surger y.
to the specific problem. The absence of other findings, He is allergic to penicillin. He denies tobacco use. He
called “pertinent negatives,” likewise may suggest a cer- works full-time in computer sales.
tain diagnosis and help rule out other diagnoses because Based on the information in this note, answer the
of their absence. Consider the history of a 22-year-old following questions:
man who presents with low-grade fever and right lower
1. How long has the patient had left knee pain?
quadrant abdominal pain. The DDX of acute appendi-
2. Has he tried anything to relieve the pain?
citis should come to mind. Patients with this condition
3. What per tinent positives and negatives are docu-
typically present with anorexia, or loss of appetite. If this
mented? Are there any other per tinent elements
man has anorexia, that is a pertinent positive finding and
of the patient’s histor y that should have been
would support the DDX of appendicitis. If he states
documented?
that he is hungry and wants to know how soon he can
4. Does the patient have any chronic medical
eat, the absence of anorexia is a pertinent negative, and,
conditions?
although it does not rule out appendicitis, it makes that
5. Has the patient had any surger y?
condition less likely. When documenting certain elements
6. Does the patient take any medications?
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 As you can see, this entry did not allow you to answer
way that you can make a diagnosis. Documenting the these questions. However, all of the information should
pertinent positives and negatives in the patient’s history be part of the history related to the patient’s CC of knee
often will help other health-care providers recognize the pain and should be documented as subjective information.
pattern of the condition the patient is exhibiting. This information is important to anyone who may be
Your documentation of pertinent positives and nega- involved in the patient’s care. Read Example 3.2, and
tives should be detailed enough to narrow the DDX and then answer these same questions.

EXAMPLE 3.2
Objective
CC: “my left knee hur ts”
S: This 42-year-old man presents with complaint of left The elements of the comprehensive H&P that are
knee pain. He originally injured his left knee about a identified as objective information are as follows:
month ago while playing softball. He states that he slid
• Vital signs (VS)
into a base and his foot caught against the bag, which
• A general assessment of the patient
twisted his knee. In the past week, the pain has gradu-
• Physical examination findings
ally worsened. He describes the pain as “a deep ache.”
• Results from laboratory or diagnostic studies
He has not noted any swelling of the knee. The pain is
worse when he stands for more than half an hour at a Objective information is what you or others can
time and when he walks and goes up stairs. The patient observe. Typically, you would document it in the
has taken ibuprofen 400 mg occasionally for the pain, order listed previously. You may document VS on a
with some relief. He denies any numbness or tingling of flow sheet or some other place in the chart, especially
the extremity or previous injur y to the knee. He does if the patient is hospitalized. If the VS are recorded
not have any chronic medical problems and specifically elsewhere, it is a good idea to record them again in
denies having a histor y of hyper tension or ulcers. He has the Objective section. Recording the specific readings
never had surger y. He does not take any medications on of the vital signs is preferred over “VS stable” or “VS
a regular basis. He is allergic to penicillin, which causes within normal limits (WNL).” It is easier and more
a rash. He is married, has two children, and is employed convenient for others who will read the note to see the
full-time in computer sales. He denies any tobacco use, actual numbers, and this allows them to make their own
drinks “a few beers a week,” and denies drug use. interpretation of the VS.
A general assessment is not always included in a
The note in Example 3.2 is longer than the one in note in an office-based encounter but is very helpful in
Example 3.1. It is also more thorough and helps answer certain settings or with certain more serious or urgent
the questions a reader was not able to answer after reading CCs. Document a general assessment in a way that
the note in Example 3.1. The note in E xample 3.2 does helps identify the patient and paints a picture of the
a better job of documenting the required elements of patient’s overall presentation and status. Identifying
the HPI as well as pertinent positives and negatives. information typically documented includes the patient’s
Notice also the use of quotation marks (“my left knee age and gender and sometimes the patient’s race. Con-
hurts” and “a few beers a week”) that indicates verbatim sider two patients who present to an urgent care center
responses from the patient. There will be times when with shortness of breath. The general assessment for
you want to include the patient’s exact words in your the first patient is documented as “a 28-year-old man
documentation; ideally, you should ask follow-up who is cyanotic, using accessory muscles and gasping
questions in order to determine exactly how often the for breath.” General assessment of the second patient is
patient consumes alcohol and how much he consumes. documented as “a 28-year-old man sitting comfortably
This would give you a better idea of whether the patient who is acyanotic and has no tachypnea or increased
has any health risks associated with alcohol use. 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
MEDICOLEGAL ALERT ! this assessment mentally, it is good practice to document
it specifically, especially in settings where patients are
When a condition or symptom involves any part of the
seen based on the acuity of their condition and not the
body that involves laterality, specify the area of concern
order in which they arrive.
and do so consistently. In Example 3.2, the patient com-
Just as it is challenging to know how much history
plained of left knee pain. Verify that you document left
to obtain and document in the Subjective portion, it
knee when you are referring to history and report left
also may be a challenge to obtain and document the
knee findings from the physical examination. Most con-
physical examination and other objective information.
ditions involving an extremity warrant examination of
The objective information should flow logically from
and comparison to the contralateral extremity. Even one
the subjective and should reflect your DDX just as
discrepancy in use of left or right could raise doubts as
the subjective does. Physical examination is usually
to which side is being examined or treated. Malpractice
taught in a system-based manner, and this may help
lawyers will look for such discrepancies and will be sure
you to know how much examination to do, which
to point them out, which might damage your credibility.
systems to examine, and how much examination to

document. Some CCs will be associated with a specific positive and negative findings from the physical
system; back pain, for instance, is associated with the examination. The history of a patient who presents
musculoskeletal system, so the physical examination with a sore throat includes the pertinent positives
would focus on the musculoskeletal system. Because of sudden onset, fever, pain with swallowing, and a
the musculoskeletal and the neurological systems are muffled voice, prompting the DDX of streptococcal
interrelated and either could be the source of the back pharyngitis. On physical examination, you would
pain, you also would perform and document a neuro- expect to see tonsillar enlargement, erythema of the
logical examination. Use the DDX of a complaint to tonsils and pharynx, and possibly exudates. Presence
help determine which systems are examined. A 34-year- of any of these findings is considered a pertinent
old woman presenting with abdominal pain has a positive and makes the diagnosis of streptococcal
DDX that includes appendicitis, cholecystitis, ovarian pharyngitis more likely than if the findings were not
cyst, sexually transmitted disease, ectopic pregnancy, there. The absence of any of these findings would be
and so on. Your documentation should indicate that a pertinent negative.
both the gastrointestinal (GI) and the gynecological
(GYN) systems were examined. If DDX arising from Formats for Documenting Objective
systems other than GI and GYN are considered, then Information
you also should examine the associated system(s) or Two formats are commonly used for documenting
body area(s). the Objective portion of a SOAP note. Example 3.3
Typically, you would perform the physical exam- shows the narrative format, and Example 3.4 shows the
ination in a head-to-toe format. You can modify this system-heading format. Either format is acceptable;
approach as needed, omitting systems that do not which one is used is determined by the facility and may
need to be examined in a problem-focused encounter be influenced by the method of documenting, whether
or saving the examination of a system for last because paper-based or computer-based. Some health-care
of discomfort for the patient. Regardless of the order providers prefer the system-heading format because
in which the examination is performed, you should the use of headings makes it easier to find specific
document it in head-to-toe order. The suggested order information. Instead of reading the entire Objective
of documenting a physical examination is shown in section, a reader can go quickly and easily to the system
Table 3-1. You should be aware that there are vari- related to the CC. If using the system-heading format,
ations of this format. Some providers will document omit the heading for any system not examined. It is not
the respiratory and cardiac examinations under the necessary to include the heading and then document
heading CHEST. Some will document pulses under “not examined” or “not pertinent.”
the heading of EXTREMITIES rather than in the
cardiovascular system. These are acceptable variations. EXAMPLE 3.3 NARRATIVE FORMAT
The content of the documentation is usually far more
important than the format. The patient is a 42-year-old man who is aler t and coop-
Just as there are pertinent positive and negative find- erative. His temperature is 98.2, respirations 20, pulse
ings from the history, typically there will be pertinent 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
Table 3-1 Order in Which to Document
is straight without any tenderness over the ver tebral
Objective Information for SOAP
bodies. The upper extremities show full ROM of all
Note
joints. Left leg is without any swelling or deformity.
• Vital signs: temperature, respiration, blood pressure, There is tenderness to palpation at the medial aspect
height, weight, body mass index (BMI) of the left knee; no obvious dislocation of the patella.
• General assessment The anterior drawer sign is negative. There is full ROM
• Skin of the left hip and knee without crepitance. McMurray
• Head, Eyes, Ears, Nose, Throat (HEENT) test is positive at the left medial aspect. The right leg is
• Neck without any swelling or deformity. There is no tender-
• Chest ness to palpation. Full ROM of the right hip and knee.
• Abdomen Negative anterior drawer sign and negative McMurray.
• Genitourinary or gynecological Muscle strength 5/5 bilaterally. Cranial ner ves II to XII
• Extremities are grossly intact, and there are no focal neurological
• Musculoskeletal deficits. Straight leg raise is negative bilaterally. Patellar
• Neurological and ankle reflexes are 2+ bilaterally.

EXAMPLE 3.4 SYSTEMS-HEADINGS FORMAT having the test result specifically documented because
General: The patient is a 42-year-old man who is
this will give them the opportunity to make their own
aler t and cooperative. His temperature is 98.2,
interpretation of the results and save the time of having
r espirations 20, pulse is 88, and BP is 126/64.
to look up results that may be documented elsewhere
HEENT: The head is normocephalic and atraumatic.
in the medical record.
The pupils are equal, round, and react to light.
If you plan to order diagnostic tests but do not have
Neck: The neck is supple without any masses.
the results at the time you are documenting, this is
Musculoskeletal: The spine is straight without any
usually documented as part of the plan instead of an
tenderness over the ver tebral bodies. The u pper
objective finding. This is because there are no results to
extremities show full ROM of all joints. Left leg
observe or document yet. Consider the 42-year-old man
is without any swelling or deformity. There is
presented in Example 3.2 who presents with left knee
t enderness to palpation at the medial aspect of
pain. After gathering the problem-specific history, or
the left knee; no obvious dislocation of the patella.
subjective information, you perform the problem-specific
The anterior drawer sign is negative. There is full
physical examination (objective information). You
ROM of the left hip and knee without crepitance.
decide to order an x-ray of the knee. If you cannot
McMurray test is positive at the left medial aspect.
perform the x-ray on site, the patient will have to go
The right leg is without any swelling or d eformity.
to an outpatient facility. Dr. al Zahid, the radiologist
There is no tenderness to palpation. Full ROM of
at the facility, typically telephones with the results of
the right hip and knee. Negative anterior drawer
the x-ray, so you ask the patient to return to your office
sign and negative McMurray. Muscle strength 5/5
after the x-ray is taken. When you get the results, you
bilaterally.
document “x-ray of the left knee is negative for any
Neurological: Cranial ner ves II to XII are grossly
fracture or other acute findings per Dr. al Zahid.” If
intact, and there are no focal neurological deficits.
you perform the x-ray on site, or if the patient returns
Straight leg raise is negative bilaterally. Patellar and
with the x-rays taken at another facility, you would view
ankle reflexes are 2+ bilaterally.
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”).
Documenting Diagnostic Test Results
You should document the results of laboratory or other Interventions Done During the Visit
diagnostic tests in the Objective portion of a SOAP You should document any interventions done during
note. Tests that may be ordered for a 34-year-old woman the visit in the Objective section. Suppose the patient
who presents with abdominal pain include a complete described in Example 3.2 is seen at 5:30 p.m. You cannot
blood count (CBC), basic metabolic panel (BMP), take x-rays on site, and the outpatient facility where he
urinalysis (UA), urine pregnancy test, and abdominal would have an x-ray done is closed. In the meantime,
ultrasound. The results of these studies would generally you provide a knee immobilizer and instruct the patient
follow the documentation of the physical examination. on crutch walking. Document these interventions in the
Give the name of the test first, then the result (e.g., Objective section of the note. Obtaining an x-ray is part
CBC shows a white blood cell (WBC) of 5.8, hemoglobin of your plan, which is discussed later in this chapter. If
(Hgb) of 11, and hematocrit (Hct) of 34). If all the the patient were instructed to return tomorrow after
results are within normal limits, you may document x-rays are taken, that would also be part of the plan.
as “the CBC is WNL.” If one component of a panel Use Application Exercise 3.1 to test your skills in
of tests is abnormal, but the rest are normal, you could differentiating between content that belongs in the
document “BMP shows a potassium of 5.2; otherwise, Subjective part of a note and information that belongs
the results are WNL.” Other readers will appreciate in the Objective part of the note.

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.

____ Patient is hard of hearing.

____ No respiratory distress is noted.
____ Patient denies allergies to any medication.
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
In Application Exercise 3.2, read the subjective

documentation, and answer the questions that follow.

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.

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
Adhering to the recommended head-to-toe order of Exercise 3.3 the order in which each finding should
documenting the physical examination in the Objec- be documented.
tive portion of a SOAP note, indicate in Application


________ 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.
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.
Assessment dysuria, and the DDX of urinary tract infection (UTI) is

considered. A pertinent positive finding from the physical
Careful analysis and interpretation of the subjective examination is mild suprapubic tenderness. UA shows 2+
and objective data should lead to a logical assessment. leukocytes, trace nitrites, and microscopic hematuria, but
Impression, diagnosis, and assessment are terms used in- it is otherwise negative. The UA is suggestive of a UTI
terchangeably. Upon reading the CC, you can formulate but does not confirm the diagnosis. Other conditions
a DDX. Table 3-2 shows examples of DDX for four considered in the DDX could be causing the patient’s
common complaints. symptoms and the UA findings. If the result of a urine
As subjective and objective data are assimilated, you culture is positive, then the diagnosis of a UTI can be
can refine the list of DDX. Laboratory and other diag- made definitively. There are times when you will not be
nostic studies may help confirm a suspected diagnosis, able to make a definitive diagnosis at a single visit, such
although such studies are not always necessary to reach as when additional testing is indicated but not readily
a final diagnosis, as in the case of sinusitis. A definitive available and must be scheduled for a later time. If a
(or final) diagnosis is based on diagnostic evidence. For definitive diagnosis has not been reached, a symptom
example, a patient may present to the clinic complaining of 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.
Table 3-2 Examples of Differential Diagnoses
Based on Chief Complaint EXAMPLE 3.5
Chief Complaint Differential Diagnoses Symptom ICD-10 Definitive ICD-10
Headache Tension headache, migraine Diagnosis
headache, cervical myofasciitis, Dysuria R30.0 Urinar y tract N39.0
sinusitis, cerebrovascular
accident, space-occupying lesion infection
Eye pain Trauma, conjunctivitis, corneal Right knee M25.562 Osteoar thritis M17.31
abrasion, sinusitis, orbital cellulitis, pain of right knee
glaucoma, keratitis, ocular Left ear pain H60.12 Acute otitis H65.02
migraine, hordeolum
media, left ear
Vaginal discharge Candidiasis, bacterial vaginosis,
trichomonas, chlamydia, gonorrhea Right lower R10.31 Acute K35.80
Diarrhea Infection, irritable bowel quadrant appendicitis
syndrome, food intolerance/ pain
allergy, ulcerative colitis, antibiotic
induced Fatigue R53.8 Anemia D64.9

The first assessment listed should usually correlate with Differential Diagnosis
the presenting complaint. As you uncover other diagnoses, When you cannot determine a definitive diagnosis,
list them in order of importance or impact on the CC. then document a list of DDX, reflecting conditions
Remember to list any comorbidities that may influence that are being considered and that may require further
the patient’s medical course. Refer to Example 3.6. workup. It is beyond the scope of this text to address
the process of developing and refining DDX. Although
EXAMPLE 3.6 generating a list of DDX is a basic skill that you can
S: This patient complains of experiencing an aching, learn with practice, it takes extensive clinical training
occasionally sharp pain in the right lower leg over the and a wealth of clinical experience to develop the
past 2 days. He noticed an open sore on the right leg higher-order critical thinking skills needed to synthe-
this morning. He has felt feverish and slightly nauseated size and analyze data in order to refine and continually
since last night. He rates the pain severity as 5/10 at narrow the DDX and arrive at a logical most likely
rest; standing worsens the pain to 8/10. He has not had or definitive diagnosis. There is certainly truth in the
any relief with Tylenol or elevation of leg. Measurement axiom, “if it is never considered, it will never be diag-
of the fasting blood sugars range from 200 to 275, and nosed”; therefore, you must be able to generate DDX
2-hour postprandial blood sugars range from 250 to for every problem with which a patient presents. It is
325. Last HgbA1C done 3 months ago and was 8.3. one thing to know that a patient has a herniated disk
PMH: Significant for type 2 diabetes and HTN. with radicular symptoms and then to consult a medical
Medications: Metformin 1,000 mg BID; Glyburide 5 mg textbook about the particulars of that condition. It is
BID; Lisinopril 20 mg daily. another thing altogether to have a patient in front of
Allergies: NKDA you who presents with back pain or numbness in the
Social: 30-pack-year history of cigarette smoking; quit leg and to have to go through the process of investi-
2 years ago. Denies alcohol or drug use. gating a symptom and arriving at a certain diagnosis.
O: General assessment: 68-year-old man who is alert That process is a complex and multifaceted one, and
and oriented but looks mildly distressed. this text makes no attempt to teach clinical reasoning
VS: BP 156/94; P 94; R 20; and T 97.0. Wt 235, Ht 70” or medical decision-making but aims to present only
Heart: RRR without murmur. a brief discussion of the importance of documentation
Lungs: Adventitious breath sounds throughout all lung fields. that reflects the subjective and objective data that you
Extremities:There is a 2-cm superficial ulceration on the gathered about a symptom or specific problem, doc-
right lower leg proximal to the lateral malleolus with umenting an assessment or assessments that reflect
4-cm area of surrounding erythema and increased analysis of such data and support a plan of care. It may
warmth. Dorsalis pedis pulses are 1+ and equal.There be helpful for you as a student or novice health-care
is decreased sensation from the midcalf to the toes provider to consult symptom-based books as a starting
bilaterally. point to developing DDX (see the Bibliography for
A: Ulcer right lower leg S81.801 specific references).
Cellulitis right lower leg L03.115 When documenting the DDX, list in order of most
Type 2 diabetes, poorly controlled E11.65 likely to least likely. The list does not need to be all-
Diabetic neuropathy E11.40 inclusive but should demonstrate thoughtful analysis
Essential hyper tension I10 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,
MEDICOLEGAL ALERT ! laboratory and imaging services are readily available;
having the results of diagnostic studies at the time of
Be careful that you do not document or code a diag-
the encounter may establish a definitive diagnosis.
nosis until it has been proven definitively. Documenting
When these services are not available, documentation
an unproven diagnosis may adversely affect the patient’s
of the plan should reflect which studies are needed and
present and future health care. It could also result in in-
how the results will guide you to formulate a treatment
appropriate coding.
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 ulcer and cellulitis of the right lower extremity the DDX. Note that an ICD-10 code is listed only for
represent the presenting complaint, whereas the poorly the presenting symptom, and no codes are listed for the
controlled type 2 diabetes, neuropathy, and hypertension DDX. This is to prevent a diagnosis being inadvertently
are comorbid conditions that may affect his overall added to a patient’s record or submitting billing for a
medical course and outcome. diagnosis that has not yet been proven.

EXAMPLE 3.7 DDX: otitis externa, otitis media, eustachian tube

dysfunction
A: Left lower quadrant abdominal pain (R10.32)
A: Left calf pain (M79.662)
DDX: diver ticulitis, ovarian cyst, ureterolithiasis
DDX: deep vein thrombosis, cellulitis, muscle strain
A: Right great toe pain (M79.674)
DDX: gout, ar thritis, fracture
A: Right ear pain (H92.01) Test your skills related to generating the DDX in
Application Exercise 3.4.

List several DDX for the following CCs:
Neck pain
Low back pain
Cough
Epistaxis
Shortness of breath
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
Plan 6. Disposition/follow-up instructions: when the

patient is to return, the conditions or symptoms
This section of the SOAP note includes documentation that indicate the patient should return sooner,
of diagnostic studies that will be obtained, referral to and when to go to another facility such as an
other health-care providers, therapeutic interventions, emergency department, urgent care center,
education, disposition of the patient, and any planned specialist, or therapist.
follow-up visits. Each problem or diagnosis documented
in the Assessment portion should be addressed in the Laboratory and Diagnostic Tests
Plan portion. The details of the Plan portion should Additional testing may be necessary to establish or
follow an orderly manner, which may vary depending evaluate a condition. Laboratory and imaging studies,
on your practice setting. One suggested format is the physiological assessments, and other evaluations not
following: performed during the patient encounter are components
1. Additional laboratory and diagnostic tests. of the Plan section. Some tests, such as magnetic reso-
2. Consults: referrals to specialists, therapists nance imaging (MRI), may require prior authorization
(physical, occupational), counselors, or other from the patient’s insurance carrier. Documentation
professionals. should establish the rationale for any testing ordered
3. Therapeutic modalities: pharmacological and by the health-care provider.
nonpharmacological management.
4. Health promotion and disease prevention: ad- Consults
dress risk factors as appropriate and consider Specialist consultations or referral to other health-care
age-appropriate preventive health screening and providers may be needed to establish a definitive diag-
immunizations. nosis, to evaluate a known condition, or for treatment of
5. Patient education: explanations and advice given an acute or chronic condition. For example, you might
to patients and family members. refer a patient with right lower quadrant (RLQ) pain to

a surgeon to be evaluated for possible appendicitis. Often control over their health and its determinants, and
you will refer pregnant women to an obstetrics-gynecology thereby improve their health.” Health promotion
(OB/GYN) specialist for obstetric management. You and disease prevention programs often address social
could refer a pediatric patient with speech difficulties to determinants of health, which influence modifiable
a speech therapist for evaluation and management. You risk behaviors. Modifiable risk behaviors include, for
may refer a patient to a physical therapist for evaluation example, tobacco use, poor eating habits, and lack of
and treatment of injuries and musculoskeletal problems. physical activity, which contribute to the development of
Many insurance companies require an authorization for chronic disease. Disease prevention focuses on strategies
such consults. A copy of the medical record pertaining to reduce the risk of developing chronic diseases and
to the complaint is frequently reviewed to establish the other morbidities. Another aspect of disease prevention
“medical necessity” of the consultation. Thorough doc- is through routine screening tests. Documentation of
umentation is critical in justifying the need for service. immunization status is an important part of disease
prevention. Specific aspects of health promotion and
Therapeutic Modalities disease prevention are addressed for pregnant women,
Pharmacological Treatment pediatrics and adolescents, adults, and older adults in
Chapters 4 through 7, respectively.
Frequently you will prescribe medications for patients
to treat illnesses, conditions, or symptoms. You must Patient Education
document specific details of the prescribed medication,
Education is such an important aspect of health pro-
such as name, dose, route of administration, frequency of
motion and disease prevention that it deserves special
administration, and duration. Prescription writing is covered
mention. When a patient has a positive encounter with
in Chapter 9. If you recommend an over-the-counter
a health-care provider, it is often because the provider
(OTC) medication, then you would document the same
took time to explain the diagnosis and treatment
details listed earlier for prescription medications. When
plan. Most patients want to know what is causing
prescribing or recommending a medication for use as
their symptoms, what their treatment options are, the
needed (PRN), your documentation should indicate
expected outcome, and why or when to return to the
what condition or symptom the medication is intended
office. When you prescribe or recommend medication,
for, for example, diphenhydramine 25 mg 1–2 tablets
you should inform the patient about the benefits and
every 6 hours PRN itching.
risks and potential side effects. Educating patients about
Documentation also should address any change in
their condition or disease enables them to take control
current medications, such as adjusting the dosage or
of their health. Patient satisfaction surveys report that
frequency or discontinuing a medication. For example,
patient education is considered an important indicator
Mrs. Aguilar has been taking amoxicillin for sinusitis
of the quality of care received. Encourage your patients
for the past 5 days and is not improving. When issuing
to be active participants in their own health care, which
a new prescription for cephalexin, also document that
often improves compliance with treatment.
she was instructed to discontinue the amoxicillin.
Nonpharmacological Treatment MEDICOLEGAL ALERT !

A wide variety of nonpharmacological treatment modalities
may be included in the patient’s overall management Documentation of patient education is not only good
plan. Often you may recommend behavioral and lifestyle medical practice, but also it may prevent a lawsuit. This
changes, such as smoking cessation, weight loss, exercise, applies to medications prescribed, tests performed,
relaxation techniques, and dietary adjustments. Specific consents obtained, warnings, recommendations, patient
instructions may include “drink plenty of fluids and rest” education, and follow-up instructions.
or “rest, ice, compression, and elevation” (RICE) of an
injured extremity. Dressing changes, activity modifica-
tion, and monitoring parameters (e.g., blood pressure Printed handouts are valuable tools to reinforce
and blood glucose levels) are all nonpharmacological instructions given verbally to patients. There are many
treatment modalities. Patient education is an important resources available on just about any condition that you
adjunct to therapeutic recommendations. might encounter. Some books have tear-out sheets to
give to patients. Others have pages you can photocopy.
Health Promotion and Disease There are software programs and websites that allow
Prevention you to customize and personalize handouts with your
The World Health Organization defines health pro- office logo and information. Pharmaceutical companies
motion as “the process of enabling people to increase may provide patient education materials; for example, a

company that makes insulin will offer handouts related or you may instruct the patient to go to an urgent care
to care of a diabetic patient, such as dietary information, center or emergency department if a serious problem
logbooks for patients to record blood glucose readings, develops.
and other educational materials for patients and their You can determine the time frame for routine
families. Documenting which handouts and materials follow-up by how soon you would expect a patient to
you give the patient may prompt you to inquire about exhibit a response to the treatment initiated. If a patient
the patient’s understanding of the material at a sub- has been taking antibiotics for otitis media, you would
sequent visit. Simply providing written material to expect the patient to improve within 48 to 72 hours;
the patient does not meet your obligation to provide therefore, documentation would include “follow up
education. You should determine the patient’s ability if not improved in 2 to 3 days.” Consider potential
to read and understand the material before distributing complications that could occur; in the case of otitis
written materials. Figure 3-2 is an example of a patient media, meningitis is a rare but serious complication.
education handout. Document the specific symptoms that indicate the
need for evaluation, such as persistent fever, headache,
Follow-Up Instructions vomiting, or neck stiffness. This is especially important
It is important to document follow-up instructions at for pediatric patients and in situations in which the
every patient visit, regardless of the reason for the visit. patient’s condition could deteriorate rapidly. Failure to
Specific information that you should document includes document your instructions to the patient is considered
when the patient should return for follow-up, signs or failure to provide those instructions.
symptoms that could indicate worsening of the patient’s Follow-up visits are an opportune time to ask patients
condition, and what to do if those signs or symptoms whether they have any questions about what was discussed
develop. You may advise the patient to call your office at previous visits. Encouragement and reinforcement
for further instructions. You may determine that the will promote patient understanding of the condition and
patient should return to the office for re-evaluation, compliance with treatment, which, in turn, may lead to
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.
Figure 3-2 Sleep hygiene guide.

Figure 3-3 One example of a complete office note in an EMR from theAuthor
HPI through the physical
ISBN # Author's review
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a more favorable outcome. Numerous studies indicate documentation of pertinent positives and pertinent
that communication between clinician and patient is negatives helps to demonstrate a pattern. Obtaining
the single most effective predictor of patient adherence and documenting subjective information is often
to a treatment plan. If you use effective communication the most time-consuming part of the encounter but
skills, the patient will become an educated participant often will lead to the diagnosis. The subjective infor-
in the treatment, thereby increasing the likelihood of mation guides what physical examination should be
compliance. The concept of effective clinician-patient done. When documenting the objective information,
communication is a necessity, not an option. painting a picture of the patient’s presentation by
Figure 3-3 shows a complete office note in an EMR documenting a general assessment helps to provide
from the HPI through the physical examination of each context for the encounter. Taken together, the subjec-
body system to the assessment and plan. tive and objective information should lead to logical
assessments, impressions, or differential diagnoses.
Once the final assessment is determined, the plan
Summary documents what actions you will take to treat the
patient’s condition. To reinforce the content of this
SOAP notes provide a format to document problem-focused chapter, please complete the worksheets that follow.
encounters when a comprehensive H&P is not needed. Worksheets 3.4, 3.5, and 3.6 include SOAP notes for
The SOAP note is adaptable to different practice set- encounters in different practice settings, written by
tings. It takes years of clinical practice to develop the various providers. Compare and contrast these notes
judgment necessary to determine how much history and how they are adapted for the chief complaint
to obtain and how much physical examination to and setting of care. And be sure to review Appendix
complete and document. Consider that much of the A, the Document Library, for full case examples of
process of making a diagnosis is pattern recognition; patient documentation.

Worksheet 3.1
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

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.

Worksheet 3.2
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 3.3
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 3.4
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.
S:
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
-DVRQ:LOVRQ3$6,,
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.


Worksheet 3.5
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.
S:
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.
-DFTXHOLQH0LWFKHOO0'

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documentation.

documentation.







Worksheet 3.6
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.
documentation.

documentation.








S:
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.
0DOLD<D]]L3$&

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Worksheet 3.7
Name
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

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?


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.

Worksheet 3.8
Name
Abbreviations
in this chapter.
BMP CBC
CC DDX
EMR FH
GI GYN
H&P HPI
Hct MRI
Hgb OTC
ICD-10 PRN
OB/GYN RLQ
PMH ROS
RICE SOAP
SH UTI
UA WBC
VS WNL

PART II Documentation Related to Outpatient Care
Chapter 4
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.
Ideally, women who want to become pregnant will

Introduction be counseled on preconception care during regular
health-care visits; however, prenatal care is often the
Good prenatal care depends on many factors but is
primary way young women access basic health care.
facilitated by a good prenatal record. The prenatal record
With that in mind, health-care providers should look
guides and documents the delivery of prenatal care.
at prenatal care in the context of risk assessment, health
Standard prenatal record systems facilitate the transfer of
promotion, and risk-directed intervention in general
information, incorporate risk assessment, and are revised
and not just from an obstetric perspective. This means
and updated regularly. The use of standardized prenatal
that a broad range of issues must be systematically
care records helps to ensure complete documentation
and consistently addressed and documented during
of the care provided throughout a woman’s pregnancy.
prenatal visits. Women who have prenatal care in the
This can be beneficial in the event of medical or legal
first trimester have better outcomes than women with
questions regarding the care provided. Several excellent
little or no prenatal care. Once pregnancy is confirmed,
standardized prenatal record systems are available.
there is a well-established timeline of prenatal care. The
Prenatal records vary from simple notes made on blank
first prenatal visit usually takes place between weeks 8
sheets of paper to highly developed computer-based
and 12. Typically, prenatal visits for women with average
systems. Among some of the most widely used are the
risk occur monthly through week 28. Visits are every
American College of Obstetricians and Gynecologists
two weeks from 28 to 36 weeks, and from week 36 to
(ACOG) prenatal record and the Maternal/Newborn
delivery, patients are seen weekly. The frequency and
Record System. Some offices and institutions develop
timing of visits may change if a patient is determined to
their own prenatal record forms to fit the special needs
have a high-risk pregnancy. Around 38 weeks, prenatal
and interests of the providers using them. The major
records are sent to the facility where the patient plans to
disadvantage of individually developed record systems is
deliver. Some electronic medical record (EMR) systems
that they may not be updated regularly and may result
have features that transfer prenatal information into
in suboptimal care.
the neonatal record.
79

Documentation of first day of the last menstrual period (LMP), and then
calculate the preliminary estimated due date (EDD;
Prenatal Care also, estimated date of confinement, or EDC). It is
important to determine the correct EDD because it
Demographic Information will guide the remainder of the patient’s prenatal care.
Basic demographic information includes the patient’s Obstetric history should include gravidity (sometimes
age, marital status, relationship between the father of referred to as gravida and documented as G) and parity
the baby and the patient, occupation, self-identified (sometimes referred to as para and documented as P).
ethnicity, religious preference, educational background, Gravidity indicates the number of times a woman has
and contact information. Demographic information can been pregnant, regardless of the pregnancy outcome.
be important in evaluating risk (e.g., available support Each pregnancy is counted only one time, even if the
systems, living arrangements), guiding educational plans pregnancy was a multiple gestation, such as twins or
(e.g., educational level and preferred language), and triplets. A current pregnancy, if any, is included in
identifying potential cultural or religious restrictions that this count. Parity reflects the total number of births
may affect care during the pregnancy (e.g., unwilling to after 20 weeks, regardless of the number of fetuses
accept blood transfusions). Payer information is often or outcomes. Abortus means pregnancy loss for any
documented as well. reason, including abortion and miscarriage. Another
way to document a more complete description of
Maternal History pregnancy outcomes is to record the number of term
During the initial prenatal visit, you will collect most deliveries, preterm deliveries (prior to 37 weeks),
of the information that you will use to evaluate ob- abortions, and live births (remembered by using the
stetric risks and determine what special interventions, acronym TPAL). Table 4-1 describes what specific
if any, might be needed at delivery. Risk assessment information should be elicited in each history section.
is accomplished primarily by obtaining a detailed The initial prenatal visit also should include maternal
maternal history, by performing a comprehensive and paternal screening for disorders that have a genetic
physical examination, and by performing screening tendency, including thalassemia, neural tube defect,
laboratory tests with the goal of identifying risk fac- congenital heart defect, Down syndrome, Tay-Sachs,
tors to prevent an adverse outcome to the pregnancy. Canavan disease, cystic fibrosis, Huntington chorea,
Specific maternal history that you should document sickle cell disease or trait, mental retardation, autism,
includes menstrual history, previous obstetric history, recurrent pregnancy loss or stillbirth, hemophilia, and
past medical and surgical history, and infection history. muscular dystrophy as well as any birth defects other
For menstrual history, document whether the patient than those listed.
has regular or irregular menses as well as the number Based on your reading, complete the application
of days in the patient’s menstrual cycle. Document the exercise that follows.

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___
1. G3, P2, A1
2. G3, P0, A2
3. G3, T1, P1, A0, L3

Chapter 4 Documenting Prenatal Care and Perinatal Events | 81
Table 4-1 Detailed Maternal History
Menstrual History Past Medical History

• Last menstrual period (LMP) • Immunization status
• Age at menarche • Diabetes
• Frequency of menses • Hypertension
• Length of menstrual cycle • Heart disease
• Autoimmune disorders
Previous Obstetric History
• Kidney disease/UTIs
• Date(s) of delivery • Psychiatric illness, including depression
• Gestation in weeks • Neurological/seizure disorders
• Length of labor • Hepatitis/liver disease
• Birth weight • Varicosities/phlebitis
• Delivery type (vaginal, cesarean) • Thyroid dysfunction
• Anesthesia type • Pulmonary disease
• Place of delivery • Medication allergies
• Perinatal mortality • Gynecological surgery
• Preterm labor • Surgeries/hospitalizations
• Gender of baby/babies • Anesthesia complications
• Complication • Abnormal Pap smears
• Gravida and para status • Uterine anomaly
• Any stays for neonatal intensive care • Exposure to diethylstilbestrol (DES) in utero
Infection History • Infertility
• Tuberculosis exposure • Blood transfusions
• Genital herpes • Trauma/intimate partner violence
• History of sexually transmitted infections, such as gonor- • Use of tobacco, alcohol, illegal drugs by amount,
rhea, chlamydia, human papillomavirus, syphilis, HIV frequency, and length of use
• Rash or viral illness since LMP • Complete medication history, including all prescribed
• Risk factors and immunization status for hepatitis B and over-the-counter medications, herbal and dietary
• Risk factors for HIV supplements, and vitamins
Physical Examination is detected, obtain an ultrasound to assess fetal age and

It is equally important to document the initial physical viability. Document fundal height or assessment of fetal
examination. Be sure to record maternal height, prepreg- growth at each visit from 20 weeks to delivery. If maternal
nancy and current weight, and body mass index (BMI) at BMI is greater than 40, consider an ultrasound to assess
the initial visit. You should document maternal weight at fetal growth at 28 and 32 weeks. Assess fetal presentation
all subsequent visits. Due to the number of women who after 34 weeks by Leopold maneuver and/or ultrasound.
do not seek preventive medical care, it is important to The Bishop score (also known as cervix score) is a
perform and document a comprehensive physical exam- group of measurements used to rate the readiness of
ination, as discussed in Chapter 2. A pelvic examination the cervix for labor. The Bishop score consists of five
done at the initial visit may identify cervical and pelvic measurements of the cervix: dilation, effacement, station
abnormalities, and you should document the size of the of the fetus, position, and consistency. Scores range from
uterus in conjunction with estimated gestational age. The 1 to 10; if the score is more than 8, the probability of
pelvic examination should include cervical cytology if vaginal delivery after labor induction is similar to that
the patient is not up to date according to the guidelines after spontaneous labor. A Bishop score of 6 or less
determined by the American Society for Colposcopy indicates an unfavorable cervix. Dilation is the most
and Cervical Pathology (ASCCP) and ACOG. Current important element of the Bishop score. Dilation is the
guidelines may be viewed at www.asccp.org and www. distance the cervix is opened, measured in centimeters
acog.org. If a pelvic examination has recently been per- (cm). Points are given from 0 to 3. Effacement (also
formed and a Pap smear is not indicated, you may consider called shortening or thinning) is reported as a percentage
omitting the examination and testing a urine sample for from 0% (normal length cervix) to 100% or complete
chlamydia and gonorrhea. (paper-thin cervix). Points are given from 0 to a maxi-
Documentation of fetal heart rate should take place at mum of 3 points for a cervix effaced to 80% or greater.
every visit. An ultrasound is used to detect cardiac activity Station is the position of the baby’s head relative to the
prior to 12 weeks. After 12 weeks, fetal heart tones can ischial spines. Negative numbers indicate that the head
be detected with a doppler ultrasound. If no heart rate is above the ischial spines; positive numbers indicate that

Table 4-2 Bishop Score Components

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
the head is below the ischial spines. Points are given Down syndrome and 97% with trisomy 18. The FTS
from 0 to a maximum of 3 points for a station of 1+ measures blood levels of free beta-human chorionic
or 2+. Position refers to the positioning of the cervix. gonadotropin (hCG) and pregnancy associated plasma
If the cervix faces front (anterior), it is more favorable, protein A (PAPP-A) at around 9 to 14 weeks. In addition,
whereas posterior is less favorable. Consistency of the an ultrasound is performed around 11 to 14 weeks to
cervix is measured on a scale of firmness from firm assess the nuchal translucency. Women should be offered
to soft. The softer the cervix, the better the chance of maternal serum alpha-fetoprotein (ms-AFP) screening
vaginal delivery. Table 4-2 shows the components of between 15 and 22 weeks to assess for neural tube defects.
the Bishop score. Although not typically completed at the first prenatal
visit, the quadruple screen test can identify about 80% of
Laboratory Data and Diagnostic Tests fetuses with Down syndrome, 80% of those with open
There are many routine laboratory screening tests that neural tube defects, and 60% with trisomy 18. This test
you should order at the first prenatal visit and then again measures blood levels of alpha-fetoprotein, beta-hCG,
at 28 weeks. At the first visit, order a confirmatory preg- estriol, and inhibin A. It is performed between the 15th
nancy test, even if the patient reports a positive home and 22nd weeks.
pregnancy test. Obtain a complete blood count (CBC) A pelvic and transvaginal ultrasound is performed to
to evaluate hemoglobin and hematocrit levels to screen determine that the pregnancy is viable and to confirm
for anemia as well as to establish baseline platelet count. the EDD. Additional ultrasounds may be performed
Be sure ABO and Rh(D) blood typing and antibody between 18 and 20 weeks to assess fetal anatomy and
status are done. Chemistry tests may include thyroid then around 30 weeks to evaluate fetal growth.
stimulating hormone (TSH) and fasting blood glucose In addition to documentation of all test results,
(FBG). Immunologic markers screen for rubella, HIV, be sure to document a treatment plan to address any
hepatitis B surface antigen, and hepatitis C. Syphilis abnormal results. It is beyond the scope of this book to
screening is done by ordering rapid plasma reagin (RPR). address medical treatment, but information on medical
Ensure that urinalysis and urine culture are done. You management and clinical practice guidelines is readily
should obtain vaginal cultures to test for gonorrhea and available (see the Bibliography).
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
MEDICOLEGAL ALERT !
consider testing for bacterial vaginosis and candidiasis.
The number of laboratory tests done during pregnancy
Genetic screening may be done for conditions such
is staggering. Review of closed malpractice claims and
as cystic fibrosis and hemoglobinopathies if indicated by
patient safety assessments reveal that inadequate tracking
maternal or paternal history. You should offer aneuploidy
of clinical laboratory and diagnostic tests is a top factor
screening options to all pregnant women presenting for
leading to patient injury, affecting not only the mother but
care, regardless of age. In addition, you can offer consul-
also potentially the developing fetus. All providers and
tation with a genetic counselor to all women considered
institutions must have a system to manage test results that
high risk due to maternal age (age 35 or over at delivery).
includes tracking tests until the results have been received,
Any patient with a personal or family history of genetic
notifying patients of the results, documenting that the
disease should be referred to a perinatologist for further
notification occurred, and making sure that patients with
evaluation once a viable pregnancy is confirmed. Prior to
abnormal results receive the recommended follow-up
performing a screening test, you should have a discussion
care. One of the strongest arguments in favor of an EMR
with the patient about possible results and subsequent
system is that it manages test results efficiently and reliably.
evaluation. There are many noninvasive screening options
Regardless of the type of system used, failure to manage
available. One example is the First Trimester Screen (FTS),
test results correctly and/or failure to document any step
a panel of screening tests that can identify about 85% of
of the process is failure to meet the standard of care.
pregnancies in which the fetus shows signs indicative of

Health Promotion and Disease least once during pregnancy and again after delivery,
Prevention every patient should be screened for risk of developing
postpartum depression using a standardized, validated
You will provide the majority of counseling related to
tool such as the Edinburg Postnatal Depression Scale
health promotion and disease prevention at the first pre-
(EPDS). The EPDS consists of ten self-reported
natal visit. You may address some topics, such as weight
items and takes less than five minutes to complete.
gain, teratogen avoidance, and medication use, at every
Interventions, such as education on coping techniques,
prenatal visit. Be sure to document immunization status,
medication, or referral to a mental health provider,
specifically for influenza and tetanus-diphtheria-pertussis
should be provided and documented as needed. If a
(Tdap) vaccines. Complete guidelines for recommended
patient admits to thoughts of or has a plan for suicide,
vaccinations for pregnant women are available at www.
she should be referred immediately to the appropriate
cdc.gov/vaccines/pregnancy and www.acog.org.
crisis response team or resource.
Nutrition
Patient Education
The initial nutritional status and the ongoing quality of
Patient education is cited as an important part of
maternal nutrition during pregnancy are widely believed
achieving a good pregnancy outcome. It is wise to
to affect the outcome of pregnancy. Women with certain
document educational interventions as further evi-
medical problems, such as diabetes or phenylketonuria,
dence of the provision of high-quality prenatal care.
have specific nutritional needs and may need referral for
It probably is not necessary to document detailed
nutrition assessment and recommendations. Educating
educational material; it is sufficient to note the topics
patients on optimal weight gain during pregnancy can
covered. Other educational topics include exercise, seat
help prevent complications during pregnancy and labor.
belt use, activities to avoid, anticipated discomforts
Excessive weight gain or failure to gain weight during
during pregnancy, and symptoms that should prompt
the pregnancy may prompt further nutritional evaluation.
urgent evaluation. Some professional organizations
Specific nutritional education should include folic acid
offer educational materials that can be customized for
and calcium supplementation as well as use of a prenatal
specific practices and are available in multiple formats
vitamin. Education should be provided on what foods
and different languages.
should be avoided or limited to prevent food-borne
During the remainder of the pregnancy, prenatal
illnesses or toxicities.
care occurs at regular intervals as stated previously.
Table 4-3 shows the history and physical examination,
Psychosocial Factors
testing and treatment, and educational topics included
At the initial prenatal visit, you will perform screening in the interval visits.
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
Documentation of Perinatal
restriction, preterm delivery, birth defects such as cleft and Postpartum Care
lip and palate, and sudden infant death syndrome.
Cessation of tobacco use is highly recommended. Delivery Note
Document that the mother was educated on the risk Labor and delivery typically takes place at a hospital and
of smoking, advised on smoking cessation, and, if the means of documenting obstetric care are dictated
applicable, given intervention materials to aid with by the institution’s record-keeping system, therefore
cessation. Alcohol is a known teratogen, and use of detailed discussion of that documentation is not pre-
alcohol during pregnancy incurs a risk for fetal alcohol sented in this text. Information about commercially
syndrome. Similarly, use of narcotics and other con- available perinatal records and software systems is
trolled or illicit substances can adversely affect fetal readily available.
well-being. Two screening tools for alcohol screening, A delivery note is used to document the outcome of
CAGE and T-ACE, and several screening tools related an obstetric admission (Fig. 4-1). In many hospitals, the
to drug use, are discussed in Chapter 6. The incidence physician in attendance at the time of delivery is respon-
of intimate partner violence (IPV) is known to increase sible for dictating a complete delivery record. A delivery
during pregnancy. Screening for IPV is recommended note serves to document some details of the delivery until
at the preconception visit, the initial prenatal visit, at the final transcribed report is placed in the patient’s chart.
28 weeks, and in the postpartum period. The rate of Typically, the delivery note is part of the maternal record;
detection can be higher when there is screening at however, some EMR systems integrate the delivery note
multiple visits rather than only the initial visit. At into both the maternal and neonatal record.

Table 4-3 Visits Throughout Pregnancy

History and Physical
Gestational Age Examination Testing and Treatment Education and Planning
Preconception to Detailed maternal history; Blood type and antibody Counsel of significant positive
12 weeks comprehensive physical screen; hemoglobin findings elicited by history, physical
examination; height, weight, and hematocrit; platelet or test results; screening for
BMI, blood pressure, pelvic count; hepatitis B surface aneuploidy; nutrition in pregnancy;
examination antigen; HIV; screening weight gain in pregnancy; obesity
for gonorrhea, chlamydia, counseling if applicable; teratogen
syphilis; urine culture; avoidance; refer for genetic
varicella titer, hepatitis counseling if indicated; refer to high
C, tuberculosis testing; risk if indicated
influenza vaccination
12–16 weeks Interim medical and First trimester screen Safe sex during pregnancy; exercise
nutritional history; fetal (FTS); diabetes screening and fitness during pregnancy;
movement; weight and at 12 weeks; influenza managing work during pregnancy;
blood pressure; fetal heart vaccination if not done seat belt use during pregnancy;
rate previously; urine dip for teratogen avoidance
protein and glucose
16–22 weeks Interim medical and Quad screen; ultrasound; Self-help for common discomforts;
nutritional history; fetal urine dip for protein and teratogen avoidance; fetal growth
movement; weight and glucose; progesterone for and development; general health
blood pressure; fetal heart prevention of recurrent habits; childbirth classes; emotional
rate; fundal height and preterm birth if indicated changes during pregnancy; trauma
growth protocol in pregnancy
22–28 weeks Interim medical and Hemoglobin and hematocrit; Signs of complications including
nutritional history; fetal platelet count; urine dip preterm labor and pre-eclampsia;
movement; weight and for protein and glucose; parenting and infant classes;
blood pressure; fetal diabetes screening; breastfeeding classes; contraception
heart rate; fundal height antibody screening in and family planning; work plans;
and growth; fetal lie and Rh(-) women VBAC/TOLAC if indicated
presentation
28–34 weeks Interim medical and Tdap vaccination; RhoD Self-help for common discomforts;
nutritional history; fetal immune globulin at 28–29 teratogen avoidance; fetal growth
movement; weight and weeks in Rh(-) women; and development; general health
blood pressure; fetal urine dip for protein and habits; fetal movement; anticipatory
heart rate; fundal height glucose; nonstress testing guidance regarding labor
and growth; fetal lie and after 32 weeks and delivery; infant car seat safety
presentation; screen for information; birth plan (when to
IPV; screen for depression call and where to go); physical
and emotional changes
34–38 weeks Interim medical and Repeat STI and HIV Self-help for common discomforts;
nutritional history; fetal screening; vaginal and teratogen avoidance; fetal growth
movement; weight and rectal cultures for Group and development; general health
blood pressure; fetal B strep; urine dip for habits; fetal movement; anticipatory
heart rate; fundal height protein and glucose; guidance regarding labor
and growth; fetal lie nonstress testing and delivery; infant car seat safety
and presentation; fetal information; infant safety after birth;
engagement; screen for caring for self and infant after
IPV; screen for depression delivery
38 weeks to Interim medical and Nonstress testing if Signs of labor; birth plan (when to
delivery nutritional history; fetal indicated; urine dip for call and where to go)
movement; weight and protein and glucose
blood pressure; cervical
examination; fetal heart
rate; fundal height
and growth; fetal lie
and presentation; fetal
engagement; screen for
IPV; screen for depression

Delivery Report
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.
Vaginal Delivery
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.
Figure 4-1 Sample delivery note in an EMR.

OK Correx
F04_01 6662_C_F04_01.eps Date
Initials
Artist Date
05/02/18
Check if revision X
2nd color OK Correx
B/W X 4/C 2/C PMS
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 Active movements
and legs
Reflex irritability (reaction to suction of nares No response Grimace Vigorous cry, sneeze, or
with bulb syringe) 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.
The key information that you should document in Postpartum Note

a delivery note includes the following: Often you will use the SOAP (Subjective, Objective,
• Age, gravidity (G), and parity (P) of mother Assessment, Plan) note format, discussed in Chapter 3,
• Labor progression (spontaneous or augmented) for documenting postpartum visits. Subjective informa-
• Duration of labor tion that you should document includes any complaints
• Type of delivery (vaginal, cesarean) the patient may have, ability to ambulate, pain control,
• Viability of the fetus whether patient is breastfeeding or bottle feeding, and
• Sex of the fetus ability to void. If postoperative, ask the patient about
• Presentation of fetus presence or absence of flatus. Objective findings that
• Apgar scores at 1 and 5 minutes (see Table 4-4 you should document include general assessment, vital
for criteria for Apgar score) signs, breast examination, uterine tone, fundal height,
• Weight of the fetus and amount and character of lochia. If postoperative,
• Delivery of the placenta, including number of document the appearance of the surgical incision; if the
vessels in the umbilical cord and whether the pla- patient had an episiotomy, document the appearance
centa was intact of the perineum. Be sure to include important labo-
• Uterine tone ratory data such as hemoglobin, even if normal, and
• For any lacerations or episiotomies, what extent any abnormal values from the CBC. Your assessment
and how repaired should include any problems that you identified. Your
• Estimated blood loss (EBL) plan should include any patient education provided,
• Condition of mother immediately after delivery birth control plans, and when a routine postpartum
Review the delivery note shown in Example 4.1. office visit should be scheduled. Review the postpartum
note shown in Example 4.2.
EXAMPLE 4.1
EXAMPLE 4.2
Delivery Note: Include Date and Time
Postpartum Day (PPD) # 1
This is a 27-year-old G2 now P2 who was admitted for
active labor. She progressed with Pitocin augmentation S: Patient c/o mild cramping, tolerating regular diet,
to second stage of labor. She pushed for 4 hours, 40 ambulating without difficulty. Able to void without
minutes. She delivered a viable male infant, ROA (right difficulty, no bowel movement (BM) today. Denies
occiput anterior), over a first-degree midline e pisiotomy. nausea, vomiting (N/V), shor tness of breath (SOB),
The mouth and nares were suctioned on the perineum. fever, breast tenderness. She is breastfeeding the
No nuchal cord. Apgar scores were 7 and 9. Infant weight infant and is having some difficulty getting the
7 pounds 2 oz. Intact placenta expelled spontaneously, child to latch. She would like to go home with oral
three-vessel cord. No vaginal or cer vical lacerations. contraception.
Episiotomy repaired with 2-0 chromic. The uterus was O: General: 27-year-old G2, P2 lying comfor tably in
firm with no active bleeding. The repair was done under bed and holding infant
epidural anesthesia. EBL was 500 mL. No immediate VS: T 97.8, T max: 98.9 P: 100 RR: 14 BP: 120/80
complications. Mom and baby bonding following deliver y. Resp: Clear to auscultation all fields without
wheezing

CV: Regular rate, +S1+S2, no murmur, rubs, or gallop

Breasts: + engorged, no er ythema
Summary
Abd: Soft, nontender. Fundus is one fingerbreadth Young women may not access basic preventive care unless
below the umbilicus, firm they become pregnant; therefore, you should look at
Perineum: Moderate lochia, no clots or foul odor ; prenatal care in the context of risk assessment, health
episiotomy intact, no hematoma or signs of promotion, and risk-directed intervention in general
infection and not just from an obstetric perspective. A number
Ext: No lower extremity tenderness or edema of formats are available to document p renatal care,
Labs: Mother A+, infant AB+, RPR neg, rubella including preprinted forms from national specialty
immune organizations or commercial vendors and electronic
CBC: WBC = 13.2, Hgb 9.8 systems. Prenatal records not only document the care
A: 27-year-old G2, P2 PPD #1 SVD (spontaneous that is provided, but may direct care as well. During
vaginal deliver y); no acute problems the initial prenatal visit, collect most of the informa-
P: 1. Lactation nurse to assist tion that will be used to evaluate obstetric risks and
2. D esires oral contraception, RX Micronor to determine what special interventions, if any, might be
star t at 3 weeks needed at delivery. Well-established guidelines exist
3. Continue prenatal vitamins that can guide you in obtaining and documenting a
4. Motrin and Norco 5/325 for pain; Colace BID detailed maternal history, performing physical exam-
inations throughout the pregnancy, tracking labora-
Newborn Physical Examination tory studies, and educating the patient about health
The purpose of the newborn physical examination is to promotion and disease prevention during pregnancy.
assess the baby’s transition from intrauterine life to extra- A delivery note documents the outcome of an ob-
uterine existence and to detect congenital malformations stetric admission. Postpartum notes detail maternal
and actual or potential disease. Examine the baby briefly status after delivery. Some elements of the prenatal
immediately after birth, screening for anomalies or disease and delivery records may be incorporated into the
that might mandate emergency treatment. Perform the neonatal record. Documentation of a newborn history
Apgar assessment to calculate the score at 1 and 5 min- and physical examination is critical to establish the
utes of life. Perform a complete examination within the baby’s transition from intrauterine life to e xtrauterine
first 24 hours that includes a head-to-toe examination existence. Care of the infant then transitions from the
and assessment of gestational age, frequently through a obstetric to a pediatric health-care provider; documen-
scoring system that combines physical characteristics with tation of pediatric and adolescent visits is discussed
neuromuscular development, such as the New Ballard in Chapter 5. Completing the worksheets that follow
score. Detailed information about the New Ballard score will help reinforce the content of this chapter. And be
is available at www.ballardscore.com; score sheets for sure to review Appendix A, the Document Library, for
documenting the assessment are also available through full case examples of patient documentation. You can
the website. A sample newborn history and physical follow documentation through the mother’s pregnancy
examination (H&P) is shown in Figure 4-2. and birth of the baby.

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.
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
Figure 4-2 Newborn history and physical examination.

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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.

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.

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 ASCCP
BID BM
BMI CBC
EBL EDC
EDD EMR
EPDS FBG
FTS G, P
H&P hCG
IPV LMP
ms-AFP N/V
PAPP-A PPD
ROA RPR
SOAP SOB
STIs SVD
Tdap TSH

Chapter 5
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.
and immunization guidelines are age specific; therefore,

Introduction it is important to document the date of birth accurately
and document the child’s age at each visit.
Pediatric preventive care visits, or well-child visits, are
Standardized forms can be used to facilitate doc-
often enjoyable for the provider and may provide an
umentation of preventive care visits for pediatric and
opportunity for you to interact with a patient who is not
adolescent children. Many providers use forms that have
“ill.” When obtaining subjective information, you will
been specifically developed for the Early and Periodic
often have to rely on parents or caregivers of the patient
Screening, Diagnosis, and Treatment (EPSDT) program.
to provide the medical history. Children at certain ages
This federally mandated program is the child health
are unable to voice their problems or concerns, and you
component of Medicaid and is the most comprehen-
may have to rely more heavily on the objective data you
sive child health program in either the public or private
obtain during a visit. Careful observation of the child’s
sector. EPSDT requires states to assess a child’s health
overall status and observing interactions between the
needs through initial and periodic examinations and
child and parent or caregiver are important parts of the
evaluations to ensure that health problems are diagnosed
pediatric preventive care visit.
and treated early before they become more complex and
Age is an important consideration when conducting
their treatment becomes more costly. States must perform
and documenting well-child visits. Age is documented
medical, vision, hearing, and dental checkups according
in months when the child is 24 months or younger and
to standardized schedules. Forms for these examinations
in years and months for children older than 24 months
are readily available on the Internet by using the state
(e.g., “17 months,” and “3 years, 8 months”). Generally,
name and EPSDT as the search term. In addition to
patients younger than 18 years of age are considered to
the EPSDT program, the Bright Futures program is a
be pediatric patients, although some pediatric guidelines
national initiative focused on the goals of disease preven-
include patients up to 21 years of age. Most screening
tion, risk and disease detection, and health promotion.
93

The initiative is led by the American Academy of Pediatrics Growth Screening

(AAP) and supported by the Maternal and Child Health Growth and development are important parameters
Bureau (MCHB) and Health Resources and Services that should be assessed routinely during well-child
Administration (HRSA). The Bright Futures guidelines visits. Growth generally refers to the increase in size of
provide theory-based and evidence-driven guidance the body as a whole or its separate parts. Growth charts
for all preventive care screenings and well-child visits. are used to assess and compare a child’s growth with a
Parents complete a previsit questionnaire that addresses nationally representative reference population and are
parental concerns, asks risk assessment questions, and available for boys, birth to 24 months; girls, birth to
gathers developmental surveillance information. Parents 24 months; boys, 2 to 19 years; and girls, 2 to 19 years.
are encouraged to arrive early before a scheduled visit to Growth charts provide an overview of the normal
complete the questionnaire, or if a patient portal is offered, growth trajectory of children, thus alerting the provider
to print and complete the questionnaire before the visit. to what is atypical or disturbed. The World Health
To meet the well-child visit priorities of the patient and Organization (WHO) released a new international
family, documentation forms guide health-care providers growth standard statistical distribution in 2006, which
on which questions to ask and issues to address based describes the growth of children ages 0 to 59 months
on the child’s age and stage of development. The forms living in environments believed to support what WHO
help document the visit as required by private and public researchers view as optimal growth of children in six
payers and apply proper coding to ensure payment for countries throughout the world, including the United
each visit’s activities. Forms include sections for the his- States. The Centers for Disease Control and Preven-
tory, developmental surveillance, physical examination, tion (CDC) recommends that health-care providers
screening, immunizations, and anticipatory guidance. use the WHO growth charts for infants and children
Parent/patient handouts provide an opportunity to build ages birth to 2 years and then use the CDC growth
on the topics discussed during the visit. They summarize charts for children age 2 years and older. The growth
anticipatory guidance for the visit and reinforce the Bright charts are available from the CDC and can be viewed
Futures priorities. Handouts have been developed for each at and downloaded from the organization’s website at
visit from ages 1 week to 21 years. The fourth edition www.cdc.gov/growthcharts. The measurements typically
of the Bright Futures Guidelines for Health Supervi- recorded during the first 2 years of life are length (or
sion of Infants, Children and Adolescents is available height), weight, and head circumference. After the age
in summary form at www.aap.org/en-us/documents/ of 2 years, head circumference may not be measured at
periodicity_schedule.pdf. The AAP has developed a set every visit if the child’s development has been consistent.
of Pediatric Visit Documentation Forms for well-child Body mass index (BMI) should be calculated and doc-
visits from the initial visit at 2 weeks of age up to the visits umented beginning at 2 years of age, when an accurate
for patients who are 15 to 21 years old. The forms may stature can be obtained, to screen for childhood obesity.
be viewed and ordered from the organization’s website A sample growth chart for plotting length and weight
at www.aap.org. Health history forms such as the one for age is shown in Figure 5-2. To plot the length,
shown in Figure 5-1 may also be used and can be tailored find the age across the top of the graph and then find
to a specific practice setting. 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
Components of Pediatric of the graph and the weight in pounds or kilograms
along the right axis. Follow each line to the intersecting
Preventive Care Visits point and mark. You will notice lines curving across
the chart with small numbers corresponding to each
The components of well-child visits generally follow
line at the right side of the chart. These numbers refer
the format of the comprehensive history and physical
to percentiles. Percentile is the most commonly used
examination (see Table 2-1) with minor variations related
clinical indicator to assess the size and growth patterns
to age. EPSDT-mandated components of pediatric pre-
of individual children in the United States. Percentiles
ventive care (or screening) visits include the following:
rank the position of an individual by indicating what
• Growth screening percentage of the reference population the individual
• Developmental screening would equal or exceed. For example, on the weight-
• Laboratory screening tests for-age growth charts, a 5-year-old girl whose weight
• Assessment of immunization status and adminis- is at the 25th percentile weighs the same or more than
tration as appropriate 25% of the reference population of 5-year-old girls and
• Anticipatory guidance, counseling, and education weighs less than 75% of 5-year-old girls. Based on your
• Risk factor identification reading, complete the application exercise that follows.

Chapter 5 Pediatric Preventive Care Visits | 95
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
Medical History: (Check if the child has ever had any of the following)
Allergies Bladder infection Eye problems Feeding problems
Anemia Breathing problems Hearing problems Skin problems
Asthma Bowel problems Kidney problems Sleep problems
Bedwetting Easy bruising/ Liver problems Seizures
bleeding
Serious injury (type ________)
Current Medications (please include prescription and over-the-counter medications):

Name of Medication Dose (mg) Taken how many times a day?
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 __________________
Figure 5-1 Pediatric medical history form.

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.
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.
Author ISBN #
(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])
Excess weight and obesity in children are significant than 95th percentile). The National Health and Nutrition
public health problems in the United States. A study Examination Survey (2012), or NHANES, reported the
published in the Journal of the American Medical Associ- Author obesity rates for ISBN school-aged
# Author'schildren
review (6 to 11 years of
ation ( JAMA) in 2010 reported that one of every three Sullivan age) at 17.5%6662 and adolescents (if needed) (12 to OK 19 years of age)
Correx
children in the United States is overweight or obese. Fig. #
F05_02
at 20.5%. Being
Document name
6662_C_F05_02.eps
overweight or obese during childhood
Date
The CDC recognizes four categories of weight status: Artist and adolescence Date increases the risk
Initials for developing high
03/06/18
underweight (less than 5th percentile), healthy weight AB cholesterol, Check hypertension,
if revision
respiratory
Editor's review ailments, ortho-
(5th percentile to less than 85th percentile), overweight B / W Xpedic 4/C
problems,
2/C
depression,
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diabetes. The
PMS
(85th to 95th percentile), and obese (equal to or greater Final Sizeincidence of type
(Width X Depth in Picas) 2 diabetes has increased
Date
dramatically

in children and adolescents, particularly in American milestones are identifiable skills that can serve as a guide
Indian, African American, and Hispanic/Latino popula- to normal development. Typically, simple skills need to
tions. The CDC, together with the National Center for be reached before the more complex skills are learned.
Health Statistics, developed a graph for plotting BMI There is a general age and time when most children pass
percentiles. It is shown in Figure 5-3 and is available at through these periods of development. There are also
www.cdc.gov/growthcharts. BMI calculators are readily specific speech and language milestones. Children vary
available online at various Internet sites. in their development of speech and language; however,
there is a natural progression or “timetable” for mastery
Developmental Screening of speech and language skills.
Developmental milestones are physical or behavioral Developmental screening includes subjective in-
signs of development or maturation of infants and formation from parents and caregivers and objective
children. Rolling over, crawling, walking, and talking information observed by the clinician. If a child fails
are considered developmental milestones and provide to meet developmental milestones at the appropriate
essential information regarding the child’s development. age, or if there is any suspicion of developmental delay,
The milestones are different for each age range. The then usually formal developmental testing is warranted.
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.)

05_Sullivan_Ch05.indd 98 Sullivan 6662 (if needed)
OK Correx 7/4/18 3:36 PM
There are numerous developmental tests that can be (ASQ-3). It contains 21 age-specific questionnaires,
used to screen for developmental delay. Some are aimed which allow for accurate screening anytime between
at parents, whereas others are completed by health-care 1 month and 5½ years of age. Questions ask parents to
providers. The Denver Developmental Screening Test II answer “yes,” “sometimes,” or “not yet.” It takes approx-
(DDST-II) is a 125-item standardized measure that is imately 10 to 15 minutes for parents to complete and
designed to determine whether a child’s development is 2 to 3 minutes for scoring. There is an initial cost for
within the normal range. It includes a set of questions the kit, which provides a user guide, scoring sheets, and
for parents and tests for the child on 20 simple tasks a master set of all 21 questionnaires for printing and
and items that fall into four sectors: personal-social photocopying. The third edition is available in English
(25 items), fine motor adaptive (29 items), language and Spanish; the second edition is available in French.
(39 items), and gross motor (32 items). The number More information is available at http://agesandstages
of items administered during an assessment will vary .com/products-services/asq3.
with the child’s age and ability. The DDST-II scoring
process, which is described in the screening manual, Laboratory Screening Tests
requires that the individual test items be interpreted The goal of screening is to decrease or to eliminate the
before the entire test is interpreted. Screeners must catastrophic effects of preventable mental r etardation.
be properly trained and pass a proficiency test before Genetic disease gained recognition with the introduction
using the DDST-II for clinical purposes. The test of the newborn screening program for phenylketonuria
was previously marketed by Denver Developmental (PKU). In the United States, the early screening of
Materials, Inc., in Denver, Colorado, hence the name. children for special health-care needs and congenital
As of June 8, 2015, the company has closed. However, disorders begins in the newborn period. Under the
the test, manuals, and other materials are available at direction of state public health agencies, all infants are
no cost online at www.DenverII.com. The test can be tested for certain genetic conditions, such as hemo-
used in electronic medical records (EMRs) for free. globinopathies, metabolic disorders, hearing loss, and
The Bayley Scales of Infant and Toddler Develop- other congenital conditions.
ment, Third edition (2009), also known as Bayley-III, Although newborn screening programs differ state by
is recognized as one of the most comprehensive tools state, there are national recommendations to guide and
to assess children from 1 month of age and older. With support states in the development of their program. The
Bayley-III, it is possible to obtain detailed information committee that works to set these national guidelines is
even from nonverbal children as to their functioning. called the Secretary’s Advisory Committee on Heritable
Children are assessed in the five key developmental Disorders in Newborns and Children. In addition, the
domains of cognition, language, social-emotional, motor, secretary of the U.S. Department of Health and Human
and adaptive behavior. Bayley-III identifies infant and Services reviews the committee’s recommendations. They
toddler strengths and competencies as well as weaknesses. work together to create the Recommended Uniform
It also provides a valid and reliable measure of a child’s Screening Panel (RUSP). The RUSP is a list of 34 core
abilities, in addition to giving comparison data for chil- conditions and 26 secondary conditions which every baby
dren with high-incidence clinical diagnoses. It takes should be screened for. The RUSP recommendation is
between 45 and 60 minutes to administer. A specific not a law, but it serves as a helpful guide for the states.
kit must be purchased to administer the Bayley-III. A list of conditions screened for by state may be viewed at
One tool that parents can complete is the Par- http://babysfirsttest.org/newborn-screening/states. Many
ents’ Evaluation of Developmental Status (2007), or of these tests are administered at the hospital before the
PEDS. PEDS contains 10 open-ended questions that infant’s discharge. States may require certain screenings
elicit parents’ concerns about their child. It is both to be performed more than once. Documentation of the
an evidence-based surveillance tool and a screening tests performed and the results guides care of the child
test. PEDS can be used from birth to 8 years of age. and establishes compliance with mandated screening.
It takes just a few minutes to administer and score The Bright Futures guidelines recommend that a clin-
if conducted as an interview. Less time is required if ical risk assessment for lead exposure be performed for
parents complete the questionnaire while waiting or infants at 6 and 9 months of age with blood lead testing
at home before the visit. There is also a version that to follow if positive. The guidelines also recommend
is used to assess attainment of developmental mile- that children who are enrolled in Medicaid, living in
stones, known as PEDS-DM. These tools are available housing built before 1978, or living in high-risk areas
in E nglish, Spanish, and Vietnamese. Information is as defined by the state or local health departments be
readily available at www.pedstest.com. screened for lead at 12 and 24 months of age. Public
Another screening tool that uses parent reporting health authorities in each state are responsible for
is the Ages and Stages Questionnaires, Third edition setting state and local policies.

Assessing Vaccination Status Example 5.1 shows one way to document parental
Every pediatric and adolescent visit, whether for refusal.
preventive care or evaluation of an illness or injury, is
an opportunity to assess the child’s vaccination his- EXAMPLE 5.1
tory and determine whether vaccinations need to be L.M. accompanies her 12-year-old daughter H.M. today.
administered. The CDC and the National Immuniza- I recommended administration of human papillomavirus
tion Program publish recommendations for childhood vaccine (HPV) in accordance to CDC guidelines. L.M.
(birth to 6 years of age) and adolescent (7 to 18 years stated, “I don’t want H.M. to have the vaccine.” L.M.
of age) immunizations. They also publish a catch-up states she doesn’t believe the vaccine is necessar y be-
schedule for children who were not immunized at the cause H.M. is not sexually active and that “there are too
recommended ages. The recommendations are updated many vaccines.” I discussed with L.M. and H.M. reasons
annually; visit the CDC website at www.cdc.gov/vac- for the vaccine, including prevention of HPV-associated
cines/schedules/index.html to obtain the most current genital war ts and cer vical, vulvar, vaginal, anal, and throat
schedule. The National Childhood Vaccine Injury Act cancers. We discussed specifically that HPV vaccination
(NCVIA) of 1986 and the CDC require health-care can prevent most cases of cer vical cancer. H.M. has no
providers to document the date of vaccine administra- contraindications to receiving the vaccine. I discussed
tion; vaccine manufacturer and lot number; name and with L.M. and H.M. possible mild side effects of redness,
business address of the health-care professional who swelling, and discomfor t at the injection site, fever, head-
administered the vaccine; and the Vaccine Information ache, and, rarely, severe allergic reaction; also discussed
Statement (VIS) version date and date the VIS was that benefits of preventing HPV-associated conditions
provided to the parent/guardian. Additionally, the outweigh these risks. I provided VIS on HPV vaccine
AAP recommends documentation of site and route of (12/2/2016) and discussed the information on the VIS
administration, vaccine expiration date, and a statement with L.M.; however, she refuses vaccination today.
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 You should revisit the immunization discussion at
cannot be altered. Health-care providers may add the each subsequent appointment and carefully document
name, address, and other information of their practice, the discussion. For children who are unimmunized or
but substantive changes are not acceptable. The most only partially immunized, some providers may want
current VIS must be given prior to administration of to flag the chart as a reminder to revisit the immu-
every dose of the vaccine (including each dose of a nization discussion as well as to alert the provider
multidose series). about missed immunizations when considering the
Parental refusal of vaccines is a growing concern evaluation of future illness, especially young children
for the increased occurrence of vaccine-preventable with fevers of unknown origin. The AAP provides a
diseases in children. Vaccines play a vital role in Refusal to Vaccinate Form, accessible at www.aap.org/
preventing diseases in children, so it is crucial that en-us/Documents/immunization_refusaltovaccinate.
health-care professionals understand the reasons that pdf. Although the form should not be considered a
parents are hesitant or refuse to vaccinate their children. legal document without advice from a lawyer, it may
Although there are no federal laws regarding vaccine be used as a template for documentation of parental
administration, each state has laws in place dictating refusal. If a parent refuses to sign the form, then you
which vaccinations are required for children prior to should document such refusal, along with the name of
entering schools. a witness to the refusal, in the medical record.
Anticipatory Guidance
Anticipatory guidance refers to specific topics that should
MEDICOLEGAL ALERT ! be discussed with parents and caregivers of pediatric
patients at age-appropriate levels. As children grow
If a parent refuses a recommended vaccine and the
and develop, we anticipate that they will be involved in
child later develops the disease, the issue of profes-
certain activities. For instance, many children learn to
sional liability can arise. Therefore, it is essential that
ride bicycles around 4 to 5 years of age. In anticipation
you document the parent’s refusal. Your documentation
of this, health-care providers should educate parents
should indicate that the parent was informed of why the
and caregivers to talk to the child about bicycle safety,
vaccine is recommended, the risks and benefits of vac-
wearing a helmet, wearing reflective clothing, and so
cination, possible consequences of not vaccinating, and
forth. Table 5-1 presents topics that you should address
any patient educational materials provided.
with parents and caregivers based on the age of the child.

Table 5-1 Age-Specific Anticipatory Guidance
Age at Visit Topics to Discuss
Birth to 2 Good parenting practices; postpartum adjustment; infant care/sleep positioning; injury prevention;
weeks 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.

The specific anticipatory guidance topics that should Specific screening tools have been developed for
be discussed at each age-specific visit are incorporated gathering the psychosocial history of adolescents. One
into the EPSDT and AAP forms. Be sure to document commonly used tool can be remembered by the mne-
which topics are discussed with the parent or caregiver. monic HEEADSSS, which stands for home, education/
employment, eating, activities, drugs, sexuality, suicide/
Risk Factor Identification depression, and safety. Henry Berman, MD, developed
For infants and younger children, risk factors for the original HEADS questionnaire in 1972. In 1985, it
developing diseases or conditions often are related was expanded by Drs. Cohen and Goldering to HEADSS
to the mother’s health during pregnancy. Therefore, a (adding suicide/depression screening), and this version
maternal history should be documented for all children was used for nearly 20 years. In 2004, it was updated
2 years of age or younger and may be indicated in older again to address morbidity and mortality factors. The
children if there is concern for developmental delay or second “E” (eating) was added to encourage exploration
if the child has physical abnormalities. Details of the of eating habits and screen for obesity and the third “S”
maternal history are discussed in Chapter 4 and can (safety) to screen for unintentional injury and violence.
be found in Table 4-1. Since the second version of HEEADSSS was released,
Data show that health risks in adolescents are nearly all teenagers have obtained access to the Internet
more social in origin than medical. The American and three-quarters of them use cell phones and send text
Medical Association’s Department of Adolescent messages. This utilization of media profoundly affects
Health developed the Guidelines for Adolescent the lives of adolescents; media may now contribute
Preventive Services (GAPS) with the goal of im- to 10% to 20% of any specific health problem. Thus,
proving health-care delivery to adolescents using questions on media use are critically important and are
primary and secondary interventions to prevent and included in the HEEADSSS 3.0 update. The questions
reduce adolescent morbidity and mortality. The use that comprise the HEEADSSS assessment are shown
of GAPS enables you as the health-care provider to in Figure 5-4; notice that questions are identified as
restructure the visit from a focus on traditional assess- “first line” and “if time permits or if a situation warrants
ment of wellness to identification and treatment of exploration.” Whenever possible, you should conduct
at-risk behaviors, such as drinking, unprotected sex, the interview without the presence of parents, family
nicotine use, or thoughtless or careless approaches members, or other involved adults. Regardless of the
to life. GAPS consists of 24 topics that encompass tool used, documentation of the psychosocial history is
health-care delivery, health guidance, screening, and important to identify and address situations or behaviors
immunizations. that pose a risk for the adolescent.
Electronic nicotine delivery systems (ENDS), Three out of four adolescent deaths are caused by un-
such as electronic cigarettes (“e-cigarettes”), have intentional injury (e.g., motor vehicle crashes, drownings,
been commercially available since 2004. The use of poisonings, burns) and violence (e.g., homicide, suicide).
e-cigarettes may be referred to as vaping. Youth often Risk factor screening should include questioning about
believe that e-cigarettes are safer than conventional violence—either as an observer, a victim, or an offender.
tobacco use, and they find e-cigarettes easy to conceal The FISTS mnemonic is helpful to remember screening
around adults. Studies show that youth are decreasing questions related to fights, injuries, sexual violence,
their use of conventional cigarettes while increasing threats, and self-defense strategies. Specific questions
use of e-cigarettes. Youth who were at lowest risk of for each of these categories are shown in Figure 5-5.
conventional cigarette use are becoming conventional Unfortunately, children and adolescents may also be
cigarette users after initiating with e-cigarettes. In 2015, the targets of intentional violence. Child abuse is one
more teens used e-cigarettes than regular cigarettes. of the leading causes of injury-related infant and child
You should incorporate screening for ENDS use and mortality. The Child Abuse Prevention and Treatment
exposure into the screening for tobacco use. Because Act (CAPTA) defines abuse as a recent act or failure to
ENDS products vary widely and are referred to by act that results in death, serious physical or emotional
many names, ask about use of these products by using harm, sexual abuse or exploitation, or imminent risk
specific names (e.g., electronic cigarettes, e-cigarettes, for serious harm; involves a child; and is carried out by
e-cigs, electronic cigars, electronic hookah, e-hookah, a parent or caregiver who is responsible for the child’s
hookah sticks, personal vaporizers, mechanical mods, welfare. Four types of abuse are generally recognized:
vape pens, vaping devices). As part of tobacco-use neglect, physical abuse, sexual abuse, and emotional
prevention counseling, you should include preven- abuse. Typically, these types of abuse are found more
tion counseling about the known hazards of ENDS in combination than alone. Each state is responsible
and the importance of not initiating use of any for defining child abuse and maltreatment within its
nicotine-containing products. own civil and criminal codes.

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?
(continued)

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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
Figure 5-4 The HEEADSSS psychosocial interview for adolescents.
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?
Figure 5-5 FISTS screening questions.

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The most common type of abuse is neglect. Neglect illness, or other). Questions ask if the patient experi-
is the failure of a parent, guardian, or other caregiver enced any of the traumatic experiences prior to the age
to provide for a child’s basic needs. Physical abuse is of 17 and, if a positive response, includes follow-up
nonaccidental physical injury that is inflicted by a parent, questions to assess the individual’s understanding of
caregiver, or other person who has responsibility for his or her childhood trauma. It takes approximately
the child. Such injury is considered abuse regardless of 5 minutes to complete the questionnaire. The results
whether the caregiver intended to hurt the child. Sexual are reported as severity classifications of none or
abuse includes any sexually explicit conduct or simulation minimal, low to moderate, moderate to severe, and
thereof for the purpose of producing a visual depiction severe to extreme.
of such conduct or the rape, molestation, prostitution, The Youth at Risk Screening Questionnaire is
or other form of sexual exploitation of children or incest directed at parents or adult caregivers. A list of 51
with children. Emotional abuse is a pattern of behavior behaviors is given, and parents are asked to indicate if
that impairs a child’s emotional development or sense of the item describes a youth they are concerned about.
self-worth. This may include constant criticism, threats, or Each item is assigned a point value of 1, 5, 10, 15, or 20.
rejection as well as withholding love, support, or guidance. The total score reflects the level of risk that the youth’s
Emotional abuse is often difficult to prove and, therefore, behavior will escalate without intervention. A score
child protective services may not be able to intervene of 5 to 16 indicates low risk; 17 to 32, moderate risk;
without evidence of harm or mental injury to the child. 33 to 84, high risk; and 85 or more, extremely high
Emotional abuse is almost always present when other risk. The questionnaire may be completed online;
forms are identified. Table 5-2, adapted from the Child once submitted, a results page appears along with a
Welfare Information Gateway, summarizes the signs brief list of resources, helpful interpretation material,
that suggest abuse based on characteristics of the child and additional screening resources. The online ver-
or the parent or adult caregiver. sion is available at www.scribd.com/doc/215077310/
If any type of abuse is suspected, there are stan- youth-at-risk-screening-questionnaire.
dardized tools available to assist you with additional Another screening tool is the Childhood Maltreatment
screening and documentation. The Childhood Trauma Interview Schedule—Short Form (CMIS-SF). The short
Questionnaire is a brief survey of six early traumatic form was adapted from the full CMIS, published by
experiences (death, divorce, violence, sexual abuse, John Briere, PhD, in 1992. The form is intended to be
Table 5-2 Signs and Symptoms of Child Abuse

Type of Abuse Child Characteristics Parent/Adult Characteristics
Neglect Frequently absent from school; begs or steals food or money; Appears indifferent to the child; seems
lacks needed medical or dental care, immunizations, or apathetic or depressed; behaves
glasses; is consistently dirty or has severe body odor; lacks irrationally or in a bizarre manner; is
sufficient clothing for the weather; states that there is no abusing alcohol or drugs
one at home to provide care
Physical Has unexplained burns, bites, bruises, broken bones, or black Offers conflicting, unconvincing, or no
eyes; has fading bruising or other marks noticeable after explanations for the child’s injury;
an absence from school; seems frightened of the parents describes the child as “evil” or in some
and protests or cries when it is time to go home; shrinks other very negative way; uses harsh
at the approach of adults; reports injury by a parent or physical discipline with the child; has a
another adult caregiver history of abuse as a child
Sexual Has difficulty walking or sitting; suddenly refuses to change Is unduly protective of the child or
for gym or to participate in physical activities; reports severely limits the child’s contact
nightmares or bedwetting; experiences a sudden change with other children, especially of the
in appetite; demonstrates bizarre, sophisticated, or unusual opposite sex; is secretive and isolated; is
sexual knowledge or behavior; runs away; becomes jealous or controlling with family
pregnant or contracts a sexually transmitted disease, members
particularly if younger than 14 years; reports sexual abuse
by a parent or another adult caregiver
Emotional Shows extremes in behavior, such as overly compliant or Constantly blames, belittles, or berates
demanding, extreme passivity or aggression; is either the child; is unconcerned about the
inappropriately adult or infantile; is delayed in physical or child and refuses to consider offers of
emotional development; has attempted suicide; reports a help for the child’s problems; overtly
lack of attachment to the parent rejects the child
Adapted from Child Welfare Information Gateway.

completed by interviewing the patient rather than by Table 5-4 shows neurological reflexes that should be
self-report. Questions typically start with the phrase, tested and documented during infancy. If you detect any
“Before age 17 . . .” and go on to ask about specific abnormalities on physical examination, be sure that your
events that may have occurred, such as a parent having assessment and plan address what additional testing,
problems with drugs or alcohol or an adult yelling at, if any, is indicated and what follow-up will be needed.
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 Pediatric Sports
forth. The questions explore psychological, emotional,
and physical abuse. Preparticipation Physical
You as a health-care provider are required by law
to make a report of suspected child maltreatment. For
Examination
more information, see the Child Welfare Information Many pediatric and adolescent patients will want to
Gateway publication, Mandatory Reporters of Child participate in sports activities and usually will need
Abuse and Neglect at www.childwelfare.gov/topics/sys- medical clearance to do so. The preparticipation
temwide/laws-policies/statutes/manda. An additional physical examination may be the only time a healthy
resource for information and referral is the Childhelp® adolescent will see a health-care provider, so it is
National Child Abuse Hotline (1-800-4-A-CHILD or important to include some age-appropriate screening
1-800-422-4453). Documentation should include questions and anticipatory guidance. A comprehen-
the findings that indicate possible abuse, the date the sive medical history that includes questions about a
report is made, the person to whom the report is made personal and family history of cardiovascular disease
and his or her title, and the agency (such as police or is an important component of the preparticipation
child protective services). A copy of any written report evaluation. You should document any personal history
should be incorporated into the child’s permanent of congenital or acquired heart disease as well as a his-
medical record. tory of hypertension or murmurs. Symptoms of chest
discomfort, shortness of breath, palpitations, syncope,
Age-Specific Physical or near-syncope with exercise are important. A known
family history of hypertrophic cardiomyopathy, Marfan
Examinations syndrome, or atherosclerosis, as well as a history of
unexplained sudden death in family members younger
Documentation of a newborn physical examination than 50 years of age, are all of concern. Asking about
is presented in Chapter 4. The content of the physical the use of cocaine or anabolic steroids is particularly
examination of pediatric patients includes each of appropriate. You should complete all components of
the systems shown in Table 2-1. You are encouraged an age-specific physical examination with particular
to follow the “head-to-toe” order when conducting emphasis on the respiratory, cardiac, and musculoskel-
a physical examination, but exceptions are made for etal systems. The cardiac examination should include
pediatric patients. If possible, you should auscultate auscultation with provocative maneuvers to screen for
the lungs, heart, and abdomen when the child is quiet hypertrophic cardiomyopathy because this is the most
and not crying. Some components of the examination common cause of sudden death in young male athletes.
are likely to elicit crying, such as examining the ears The recommended musculoskeletal examination is
and the oropharynx and conducting parts of the mus- provided in Table 5-5.
culoskeletal examination. Regardless of the order in Young women are less likely to experience sudden
which the examination is performed, you should always death on the athletic field than young men. In female
document in the order shown in Table 2-5. athletes, however, several predispositions should be
There are many excellent references available that considered. Anorexia nervosa and other eating disorders
teach physical examination techniques. It is beyond are more common among female athletes than among
the scope of this book to present the entire physical male athletes. Screening questions about desires to
examination for all the age-specific well-child visits. change weight or displeasure with body habitus iden-
Once a child reaches school age, the physical exam- tify many of these women. Female runners are more
ination is similar to an adult physical examination. likely to develop stress fractures than are male runners.
Table 5-3 presents a summary of physical examination Osteoporosis occurs in amenorrheic female athletes,
components that should be documented specifically and this finding should prompt further consideration
when performing infant and toddler examinations. of the possibility of an eating disorder.

Table 5-3 Documentation of Important Components of Age-Specific Physical Examinations

System Examination
Component Age Comments
Skin
Color for jaundice, All ages; most critical in neonate Jaundice that appears within the first 24 hours of
cyanosis, other birth is likely to be pathological jaundice due to
discoloration 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 Anterior fontanelle at birth measures 4–6 cm in
closed 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 Every visit Document character of any murmur present
sounds 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
(Continued )

Table 5-3 Documentation of Important Components of Age-Specific Physical Examinations—Cont’d

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 Consult physical examination reference for strategies to
if normal 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
1
Refer to a physical diagnosis reference for explanation and more information.
Table 5-4 Neurological Reflexes That Should Be Tested During Infancy*

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 Absence of placing may indicate paralysis; babies born by breech
age to disappear delivery may not have placing reflex
Parachute Develops around 4–6 Delay in appearance may predict future delays in voluntary motor
months and does not development
disappear
Trunk incurvation (Galant Birth to 2 months Absence suggests a transverse spinal cord lesion or injury
reflex)
*
Refer to a physical examination reference for a full description of each reflex and the
maneuver necessary to elicit each one.

Table 5-5 Musculoskeletal Portion of Sports Preparticipation Physical Examination

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 External rotation and stability of glenohumeral joint
and lower arms
Arms—hold out straight, then bend and straighten elbow Range of motion of elbow
Arms—hold down, bend 90 degrees at elbows, pronate Range of motion of elbows and wrists, muscle strength of
and supinate forearm 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
Summary the psychosocial history and risk assessment. Various

screening tools are available to assist you in transitioning
Preventive care visits with pediatric and adolescent pa- from a focus on traditional assessment of wellness to
tients often provide the chance for you to interact with identification of and intervention for at-risk behaviors.
children who are well and can be quite enjoyable. In the It is imperative that you are knowledgeable of findings
absence of any chronic conditions, the visits are largely that raise concern for child abuse or maltreatment and
geared to developmental screening, risk assessment, aware of mandatory reporting guidelines for the state
health promotion and disease prevention, and antici- in which you practice. You should perform age-specific
patory guidance. Documenting preventive care visits physical examinations with the goal of identifying
for pediatric and adolescent children is often facilitated any abnormalities that suggest disease, injury, or ill-
by using standardized forms that aid in meeting federal ness. Careful management of any identified problems
and state guidelines. Documentation of anticipatory should focus on maintaining health and function to
guidance provided at each visit is critical. Every visit carry the patient into adulthood. The worksheets that
is an opportunity to assess immunization status. If a follow will help reinforce concepts related to pediatric
parent or guardian refuses to consent to vaccination, then and adolescent preventive care visits. And be sure to
you must carefully document the refusal, as well as any review Appendix A, the Document Library, for full case
discussion of risks and benefits of the vaccine, and any examples of patient documentation. You can follow
education provided. As a child ages and transitions into documentation through the mother’s pregnancy and
adolescence, much of the visit focuses on documenting birth of the baby as well as the well-child visits.

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

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.

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?

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
Weight-for-age percentiles: Girls, birth to 36 months
kg lb lb
18 40 40
38 95th 38
17
90th
36 36
16
34 34
75th
15
32 32
14 50th
30 30
13 25th
28 28
10th
12
26 5th 26
11 24 24
10 22 22
9 20 20
8 18 18
16 16
7
14 14
6
12 12
5
10 10
4
8 8
3
6 6
2
4 4
kg lb lb
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)
Published by the Centers for Disease Control and Prevention. November 1, 2009.
Source: WHO Child Growth Standards (http://who.int/childgrowth/en)
05_Sullivan_Ch05.indd 115 Author ISBN # Author's review 7/4/18 3:36 PM

Length-for-age percentiles: Girls, birth to 36 months
cm in. in.
42 42
105
41 41
95th
40 40
90th
100
39 75th 39
38 38
95 50th
37 37
25th
36 36
90 10th
35 5th 35
34 34
85
33 33
32 32
80
31 31
30 30
75
29 29
28 28
70
27 27
26 26
65
25 25
24 24
60
23 23
22 22
55
21 21
20 20
50
19 19
18 18
45
17 17
cm in. in.
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)

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Head circumference-for-age percentiles: Girls, birth to 36 months
cm in. in.
56 22 22
54
21 21
52
95th
20 90th 20
50 75th
50th
48 19 19
25th
10th
46 5th
18 18
44
17 17
42
16 16
40
38 15 15
36
14 14
34
13 13
32
12 12
30
cm in. in.
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)
Indicate the percentile for each of the preceding measurements.

Weight: __________ ____________ ____________
Length: __________ ____________ ____________
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and determine whether
Date
or not
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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.
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
Weight-for-age percentiles: Boys, birth to 36 months
kg lb lb
40 40
18
95th
38 38
17 90th
36 36
16
75th
34 34
15
32 50th 32
14
30 25th 30
13
28 10th 28
5th
12
26 26
11 24 24
10 22 22
9 20 20
18 18
8
16 16
7
14 14
6
12 12
5
10 10
4
8 8
3
6 6
2
4 4
kg lb lb
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)

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Date
Length-for-age percentiles: Boys, birth to 36 months
cm in. in.
42 42
105
41 41
95th
40 90th 40
100 75th 39
39
38 50th 38
95 25th 37
37
36 10th 36
90 5th
35 35
34 34
85
33 33
32 32
80
31 31
30 30
75
29 29
28 28
70
27 27
26 26
65
25 25
24 24
60
23 23
22 22
55
21 21
20 20
50
19 19
45 18 18
17 17
cm in. in.
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)

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Head circumference-for-age percentiles: Boys, birth to 36 months
cm in. in.
56 22 22
54
21 21
95th
52 90th
75th
20 20
50 50th
25th
48 19 19
10th
5th
46
18 18
44
17 17
42
16 16
40
38 15 15
36
14 14
34
13 13
32
12 12
30
cm in. in.
Birth 3 6 9 12 15 18 21 24 27 30 33 36
Age (months)
Indicate the percentile for each of the preceding measurements.

Weight: __________ Sullivan

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Consult a pediatric textbook or history and physical examination textbook and determine whether or not
these measurements are within normal limits.

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.

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?

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 ASQ-3
BMI CAPTA
CDC CMIS-SF
DDST-II EMR
ENDS EPSDT
GAPS HPV
HRSA JAMA
MCHB NCVIA
NHANES PEDS
PEDS-DM PKU
RUSP VIS
WHO

Chapter 6
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.
eliminate, or at least delay, the onset of complica-

Introduction tions and disability due to the disease. Most medical
interventions fall into this category. One example of
According to the most recent National Ambulatory
tertiary prevention is striving for euglycemic control
Medical Care Survey (2013), ambulatory medical care
in a patient with diabetes.
in physician offices is the largest and most widely used
Health maintenance is a term that is often used
segment of the American health-care system. During
interchangeably with preventive care. Health main-
2013, an estimated 922.5 million visits were made to
tenance is a guiding principle that emphasizes health
physician offices. New patients accounted for 16.3%
promotion and disease prevention rather than the
of visits, whereas established patients accounted for
management of symptoms and illness. It includes
83.7%. Approximately 19.9% of all visits were for
the full array of counseling, screening, and other
preventive care.
preventive services designed to minimize the risk for
Preventive care is defined as medical care that f ocuses
premature illness and death and to ensure optimal
on disease prevention. This takes place at primary,
physical, mental, and emotional health throughout
secondary, and tertiary prevention levels. Primary
the natural life cycle.
prevention avoids the development of a disease. Most
It is far better to try to prevent a condition than to
population-based health promotion activities, such
have to treat it. The cost of disease management creates
as vaccines, immunization, and hand washing, are
a tremendous economic burden for government p ayers
primary preventive measures. Secondary prevention
and private insurance carriers as well as society in general.
activities are aimed at early disease detection, thereby
In addition to the economic cost of disease, there is
increasing opportunities for interventions to prevent
the physical and psychological impact on the quality
progression of the disease and emergence of symptoms.
of life of patients and their families. For these reasons,
These activities include screening measures to detect
screening guidelines for certain conditions have been
a specific condition, such as using mammography to
developed. The term screening refers to tests and exam-
screen for breast cancer. Tertiary prevention aims to
inations used to detect a disease, like cancer, in people
125

who do not have any symptoms. Current U.S. screening Risk Factor Identification Based
recommendations are focused on diseases that occur on Personal History
most frequently and that have the highest morbidity
Often indications for screening are based on the
and mortality rates. Many federal and state agencies
patient’s age. For example, the ACS recommends that
and specialty organizations, such as the American Heart
women 45 years of age and older have regular screening
Association (AHA) and the A merican Cancer Society
mammography. However, screening recommenda-
(ACS), also publish guidelines for screening. Although
tions may be different depending on certain personal
many of the recommendations are the same, there are
risk factors. Therefore, a key purpose of obtaining
variations in frequency of screening. It is beyond the
the patient’s personal medical history is to identify
scope of this book to include all the recommendations
conditions for which the patient is at risk and the
that have been published; instead, the most generally
screening measures appropriate for those conditions.
accepted guidelines are summarized. The focus of
Some risk factors are associated with personal habits,
this chapter is documenting preventive care visits for
such as a lcohol or tobacco use or dietary intake. It is
adult patients; prenatal care is discussed in Chapter 4;
important to determine whether these risk factors are
pediatric and adolescent preventive care is discussed in
present; recognize, however, that inquiring about risk
Chapter 5, and older adult preventive care is discussed
factors could appear judgmental. Inform your patient
in Chapter 7.
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
Documenting Preventive Care matters in a nonjudgmental, professional, matter-of-fact
manner should enhance patient disclosure of sensitive
Components of a preventive care visit include the
information. The following sections identify some of
following:
the risk factors that you should inquire about, and you
• Risk factor identification based on personal and should specifically document their presence or absence
family health history as part of the personal medical history.
• Appropriate laboratory and diagnostic screening
tests Exercise
• Age- and gender-specific screening, including Lack of exercise or a sedentary lifestyle is a risk factor
preconception screening for certain conditions, such as cardiovascular disease and
• Patient education and counseling diabetes, so you should encourage patients to exercise
• Assessment of vaccination status and administer- regularly. Document any information given to you by the
ing vaccines as appropriate patient related to his or her exercise habits. You should
You may use preprinted forms, such as the adult document the type of activity (e.g., walking, weight lift-
medical history form shown in Figure 6-1, to collect ing, aerobics), frequency, and duration (e.g., 30 minutes
much of the patient’s history, including personal and every other day). The current recommendation is for
family medical history. If using such a form, it is moderate activity five or more days of the week for at
important to review it thoroughly with the patient and least 30 minutes that encompasses a combination of
obtain more information about any positive responses. cardiovascular and weight training.
Specifically document that the form was reviewed
with the patient. Throughout the remainder of this Diet and Nutrition
chapter, several screening tools or questionnaires are The goal of documenting a nutritional history is to
referenced. Such tools are an excellent aid for obtaining help you identify dietary deficiencies or excesses and
and documenting important information during the then educate your patient about how to improve his or
preventive care visit. her nutritional status. Assess dietary habits by asking
When using printed forms or providing written the patient about a typical day’s food intake. Include
material, be sure to assess your patients’ level of health number of meals per day; frequency of eating out and
literacy. The U.S. Department of Health and Human types of eating establishments frequented (such as fast
Services (HHS) defines health literacy as the degree to food, restaurant, cafeteria); number of fruit and vegeta-
which individuals have the capacity to obtain, process, ble servings per day; portion size, frequency, and type
and understand basic health information needed to of protein (such as meat, poultry, seafood, dairy or soy
make appropriate health decisions and services needed products); and fiber intake. Determine the amounts
to prevent or treat illness. It is beyond the scope of this of fat (especially saturated), sugar, and processed
book to address this subject; however, information is foods that the patient consumes each day. Instead of
widely available. gathering this information by interviewing the patient,

Chapter 6 Adult Preventive Care Visits | 127
To be completed by patient
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 Bowel problems Heart problems Nerve problems
Anemia Breathing High blood Seizures
problems pressure
Alcohol/ Cancer High Skin problems
Drug addiction (type ______) cholesterol
Arthritis Depression Kidney problems Stroke
Asthma Diabetes Liver problems Thyroid
problems
Back pain Eye problems Migraine Ulcers
headaches
Blood Serious injury (type __________)
transfusion
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)

Alcoholism Asthma or Cancer Depression Diabetes Heart High Stroke Cause Age
allergies (type) disease blood of at
pressure death death
Father
Mother
Siblings
Grandparents
(Continued)

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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
Figure 6-1 Adult medical history form.
you may ask the patient to record all food intake for a risk factor for many health problems. BMI is calculated
predetermined amount of time. Then you should in- by using the following formula:
clude a copy of the food diary in the patient’s chart. If
the patient follows a vegetarian diet, document which Weight (kg) ÷ [height(m)]2 (Because height is
type (e.g., vegan, lacto-ovo vegetarian) and assess for commonly measured in centimeters, divide height in
nutritional inadequacies. Document the use of vitamins centimeters by 100 to obtain height in meters.)
and supplements taken, if any. Document the amount Weight (lb) ÷ [height (in.)]2 × 703
of water and other beverages consumed. The quantity
of caffeine consumed per day should be documented BMI calculators are readily available at many Inter-
in standard units of measure, such as how many cups net sites. BMI tables, such as the adult table shown in
of coffee or tea, number of soft drinks, energy drinks, Figure 6-2, are available from many sources. Different
and amount of caffeine-containing foods. tables are used for children and teens. Four different
categories have been identified based on the patient’s
BMI:
Body Mass Index
• Less than 18.5 = Underweight
Obesity is a serious, chronic disease that is known to
• 18.5 to 24.9 = Normal weight
reduce life span, increase disability, and lead to many
• 25 to 29.9 = Overweight
serious illnesses. Studies have confirmed a direct cor-
• 30 or greater = Obesity
relation between increases in body mass index (BMI)
and increases in the prevalence of type 2 diabetes, At the preventive visit, it is important to explore why
hypertension, heart disease, stroke, and arthritis. The the patient is obese. Teach the patient that this is a
BMI is calculated based on the patient’s height and reversible risk factor, and encourage weight management,
weight. Although these measurements are obtained nutrition, and exercise. Recognition of the need for
as part of the physical examination rather than the weight loss and accountability as well as support from
history, it is important to review the BMI with every you as the health-care provider remain key elements
patient because being overweight or obese is a major of patient success.
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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)

Tobacco Use should include
Sullivan the amount used per day
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Tobacco use is the leading preventable cause of p remature the patient

Fig. #
F06_02
has been using
Document name
6662_C_F06_02.eps
tobacco. Usually cigarette
Date
death in the United States. It is estimated that directly use is reported
Artist as a pack-year
Date
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This figure is
or indirectly, tobacco causes more than 480,000 deaths determined
AB by multiplying the number
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review
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deaths. These deaths have been attributed to a number and cigar

Final smoking is indicated
Size (Width X Depth in Picas) by frequency perDateday.
of conditions defined as tobacco-related, including Document 41p0the use of smokeless tobacco Initials
x 37p7 as the number
heart disease (124,000 deaths), cancer (163,000), of cans or pouches used per day, or sometimes per week.
chronic obstructive pulmonary disease (100,000), and It is important to educate a patient currently using any
cerebrovascular accidents (CVA) (27,000). You should form of tobacco on the health risks associated with
screen all patients for tobacco use. Document whether tobacco use and to document specifically the educa-
the tobacco use is smoked (cigarettes, pipe, cigar) or tion provided. You should ask whether the patient is
smokeless (snuff and chewing tobacco). Documentation interested in quitting.

Electronic nicotine delivery systems (ENDS), such as shows how you could document a patient’s tobacco use
electronic cigarettes (“e-cigarettes”), have been available and cessation education that you provide.
commercially since 2004. The use of e-cigarettes may
be referred to as vaping. To date, the health effects of EXAMPLE 6.1
ENDS use have not been well studied, but the nico-
The patient chews tobacco, approximately one pouch
tinergic effects are similar to traditional cigarettes. The
ever y 2 days for the past 12 years. I discussed specific
potential harmful effects of vaping have led the Food
health risks associated with smokeless tobacco, including
and Drug Administration (FDA) to issue warnings
oral cancers (cancer of the throat, tongue, and lar ynx),
regarding the risks of vaping; therefore, you should
leukoplakia, gum disease, cardiovascular disease, hyper-
document the patient’s use of ENDS as part of the
tension, and early mor tality. Patient stated that he is
social history. As with traditional tobacco use, it is
not ready to quit. I advised patient that cessation aids
not enough simply to document that a patient “uses
are available should he desire to quit.
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- If the patient formerly smoked but has quit, document
ing, but it may be challenging if using an electronic the year quit and the pack-year history. Take every
medical record (EMR), because many systems were opportunity to provide positive reinforcement to any
developed before ENDS were used commonly. It may patient who has quit smoking. Unfortunately, some
be necessary to add free-text comments in fields used to patients who quit using tobacco products will start
document other tobacco use. Remember to document again, so ask about tobacco use at every visit.
any discussions about the known risks of ENDS use Use Application Exercise 6.1 to practice calculating
and any education provided on cessation. Example 6.1 pack-year history.

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: _________
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 1 minute to administer. CAGE is an acronym formed

Alcohol consumption is associated with a number from the boldfaced letters in the questionnaire:
of physical and social problems, including reduced C. Have you ever felt the need to Cut down on
physical coordination, reduced mental alertness, poor drinking?
decision-making, double vision, and mood swings. A. Have people Annoyed you by criticizing your
Long-term chronic consumption of high levels of drinking?
alcohol leads to higher risk for heart disease, liver dis- G. Have you ever felt Guilty about drinking?
ease, circulatory problems, peptic ulcers, various forms E. Have you ever taken a drink first thing in the
of cancer, and irreversible brain damage. Screening for morning (Eye-opener) to steady your nerves or
alcohol use should be a part of every preventive care visit. get rid of a hangover?
Document the type of alcohol, amount, and frequency
of consumption. If the amount or frequency of alcohol Patients who answer affirmatively to two questions are
use is a concern, screen for abuse or dependence. This can seven times more likely to be alcohol dependent than
be accomplished through administration of the CAGE the general population. Those who answer negatively to
questionnaire, which was developed by Dr. John Ewing, all four questions are one-seventh as likely to develop
founding director of the Bowles Center for Alcohol alcohol dependence as the general population.
Studies, University of North Carolina at Chapel Hill. The sensitivity of the CAGE questionnaire was
CAGE is an assessment instrument used internationally thought to be 75%. More recent studies, however, show
for identifying alcohol dependency and takes less than that the sensitivity is lower, particularly in populations

with a lower prevalence of alcohol use, such as women Identification Test (AUDIT), which was developed by
and older adults. The CAGE test is designed to test the World Health Organization. It is accurate 94% of the
alcohol dependency over a lifetime but may fail to time and is also accurate across ethnic and gender groups.
identify binge drinkers. Furthermore, it has a greater sensitivity in populations
The FAST test consists of four questions designed to with a lower prevalence of alcoholism than the CAGE
measure a person’s hazardous drinking in the past year; screening tool. The test consists of 10 multiple-choice
answers are never, less than monthly, monthly, weekly, questions that are scored on a point system. AUDIT
daily or almost daily. The first question is “How often can be administered as a paper-and-pencil test. The
do you have eight or more drinks on one occasion?” If disadvantage of the AUDIT test is that it takes longer
a person answers “never,” then he or she is not a haz- to administer and is more difficult to score than the
ardous drinker, and the remaining questions are not shorter tests. The questions and scoring guide are shown
necessary. If a person answers “monthly” or “less than in Figure 6-3. A score of eight or more indicates an
monthly,” then the other three questions are needed to alcohol problem.
complete the screening. If a person answers “weekly” or Documentation is as simple as stating the screening
“daily or almost daily” on the first question, then he or tool used and the score, such as “CAGE score = 4” or
she is considered a hazardous drinker, and you can skip “AUDIT score of 9.”
the rest of the questions. The remaining questions are:
Use of Other Substances
1. How often during the last year have you been
unable to remember what happened the night Hazardous substance use, abuse, and dependence are
before because you had been drinking? more prevalent in the United States than some of the
2. How often during the last year have you failed to conditions that are routinely screened for, yet health-care
do what was normally expected of you because of providers sometimes fail to identify patients with sub-
your drinking? stance abuse issues. One tool that screens for substance
3. Has a relative or friend, a doctor or other health abuse is the Drug Abuse Screening Test (DAST-10)
worker been concerned about your drinking or developed by Harvey Skinner, PhD. It is a 10-item,
suggested you cut down? yes/no, self-report instrument that asks questions about
involvement with drugs in the past 12 months and should
Because of the risk for fetal harm, it is particularly take less than 8 minutes to complete. The DAST-10
important to screen for alcohol use in women who are is intended for use with patients 18 years of age and
pregnant or who may become pregnant. Studies have older. In this screening tool, “drug abuse” refers to the
shown that the T-ACE questionnaire, a four-item use of prescribed or over-the-counter drugs in excess
screening questionnaire based on the CAGE screen- of the directions and any nonmedical use of drugs. The
ing tool, is considered accurate in detecting drinking tool and scoring guidelines are shown in Figure 6-4.
problems in pregnant women. Another tool used for substance abuse screening is the
The T-ACE questions are: National Institute on Drug Abuse Modified Alcohol,
T – Tolerance: How many drinks does it take to Smoking, and Substance Involvement Screening Test
make you feel high? (NIDA Modified ASSIST). The screening may be
A – Have people annoyed you by criticizing your administered in a written version or even accessed online.
drinking? If using a written version, provide a blank cover page
C – Have you ever felt you ought to cut down on to protect patient confidentiality, and then place the
your drinking? completed questionnaire in the patient’s medical record.
E – Eye-opener: Have you ever had a drink first The NIDA Modified ASSIST may be used to screen for
thing in the morning to steady your nerves or tobacco, alcohol, and substance use and dependence. The
get rid of a hangover? first question asks, “Which of the following substances
have you used in your lifetime?” (a) tobacco products,
Affirmative answers to questions A, C, and E are each (b) alcoholic beverages, (c) cannabis, (d) cocaine, (e) pre-
scored one point. A reply of more than two drinks scription stimulants, (f ) methamphetamine, (g) inhalants,
to the T question is scored two points. The T-ACE (h) sedatives or sleeping pills, (i) hallucinogens, (j) street
is considered to be positive with a score of two or opioids, (k) prescription opioids, (l) other. If the answer
more. You should conduct further assessment, provide is “none,” then the screening is complete. If the patient
education, and implement treatment for women who answers affirmatively to using any of the substances,
screen positive in order to reduce the risk of harm to the then the next question asks if the patient has used the
developing fetus and to maximize pregnancy outcome. substance(s) in the past 3 months. Other questions ask
One of the most accurate tests available to screen how often the patient has a strong desire or urge to
for problem drinking is the Alcohol Use Disorders use; how often use of the substance has led to health,

Questions 0 Points 1 Point 2 Points 3 Points 4 Points

How often do you have a drink Never Monthly or 2–4 times 2–3 times 4 or more
containing alcohol? less a month per week times a week
How many drinks containing 1 or 2 3 or 4 5 or 6 7–9 10 or more
alcohol do you have on a
typical day when you are
drinking?
How often do you have 6 or Never Less than Monthly 2–3 times 4 or more
more drinks on one occasion? monthly per week times a week
How often during the past year Never Less than Monthly 2–3 times 4 or more
have you found that you were monthly per week times a week
not able to stop drinking once
you started?
have you failed to do what was monthly per week times a week
normally expected of you
because of drinking?
have you needed a first drink in monthly per week times a week
the morning to get yourself
going after a heavy drinking
session?
have you had feelings of guilt monthly per week times a week
or remorse after drinking?
have you been unable to monthly per week times a week
remember what happened the
night before because you had
been drinking?
Have you or has someone else No Yes, but Yes, during

been injured as a result of your not in the past
drinking? the past year
year
Has a relative, friend, No Yes, but Yes, during
doctor, or health-care worker not in the past
been concerned about your the past year
drinking or suggested you cut year
down?
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.)
social, legal, or financial problems; and how often use of If the answer to the last question is yes, you should ask
the substance has caused the patient to fail to do what about the pattern of injecting and recommend testing
was normally expected of him or her. Answers include for HIV and hepatitis B and C. For complete informa-
never, once or twice, monthly, weekly, or daily or almost tion on administering and scoring the NIDA Modified
daily. Three yes/no questions complete the screening: ASSIST screen, please visit the National Institute on
Drug Abuse website at www.drugabuse.gov.
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 Sexual History
down, or stop using the drug? Patients and health-care providers alike may not be
3. Have you ever used the drug by injection? comfortable
Author talking about the
ISBN #patient’sAuthor's
sexual history,
review
OK Correx
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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
Figure 6-4 Drug Abuse Screening Test (DAST-10). (Courtesy of Dr. Harvey A. Skinner, Dean,
Faculty of Health, York University, Toronto, Canada.)
sex partners, or sexual practices, but it is important to • Past history of STDs

emphasize to patients that taking a sexual history is a • Prevention of pregnancy
necessary part of a regular medical history. A sexual
history allows you to identify individuals at risk for Appendix B provides a list of specific questions that you
sexually transmitted diseases (STDs; also, sexually can ask to obtain the history in each of the five areas.
transmitted infections, or STIs), such as syphilis, human Then you can tailor appropriate screening measures
papillomavirus (HPV), HIV, pelvic inflammatory to the patient based on risk factors identified by the
disease (PID), and hepatitis, and helps to identify sexual history.
appropriate anatomical sites for certain STD tests. As Intimate Partner Violence (IPV)
with all parts of the history, you may need to modify
the sexual history to be appropriate for some patients Sometimes referred to as domestic violence, family vio-
based on culture or gender dynamics. lence, or relationship violence, intimate partner violence
The contents of a sexual history that should be (IPV) refers to violence occurring between people who
documented can be remembered by the five Ps: are, or were formerly, in an intimate relationship. IPV
can occur on a continuum from economic, psychological,
• Partners and emotional abuse to physical and sexual violence.
• Practices Although men are among the victims of IPV, evidence
• Protection from STDs suggestsAuthor
that most victimsISBN
are#women and
Author'sthat
reviewwomen
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are more vulnerable to its health impacts. Conduct IPV Some of the specific exposures that OSHA monitors
screening by asking three simple questions: can be grouped as follows:
1. Within the past year, have you been hit, slapped, • Mechanical: equipment-related injury, puncture
kicked, or otherwise physically hurt by someone? wounds, falls/slips/trips, impact force, compressed
2. Are you in a relationship with a person who air, high-pressure fluid injection
threatens or physically hurts you? • Physical: noise, ionizing radiation, heat or cold
3. Has anyone forced you to participate in sexual stress, electricity, dehydration
activities that made you feel uncomfortable? • Biological: bacteria, fungi (mold), virus, tuberculo-
sis, blood-borne pathogens (e.g., hepatitis, HIV)
With your patient’s disclosure of IPV, your respon- • Chemical: acids, bases, heavy metals (e.g., lead),
sibilities include acknowledging the abuse, making a solvents (e.g., petroleum), particulates (e.g., asbes-
safety assessment, assisting with a safety plan, providing tos), fumes (e.g., noxious gases, vapors), fire
appropriate referrals, and documenting. Documentation • Psychosocial: work-related stress (e.g., too much
should specifically include the victim’s description of overtime), harassment (e.g., sexual, verbal, emo-
current and past abuse, the name of the alleged perpetra- tional), burnout
tor and relationship to the victim, and any information • Musculoskeletal: carpal tunnel syndrome (CTS)
or referrals that you provide to the victim. You should and back pain, which account for one third of all
document a detailed description of all physical injuries, serious injuries suffered by American workers
including the type of injury, location (in relation to fixed
landmarks or standard anatomical regions), length, Determine the patient’s specific job duties and assess
width, shape, color, depth, degree of healing, and other risk for work-related injury or any possible exposures.
relevant details such as swelling. Include a detailed If an individual is exposed to potential hazards, ask
description of the patient’s psychological demeanor, whether the employer provides screening. Document
noting gestures, facial expressions, and other relevant the type of screening and how often the screening is
aspects. Use a body diagram to document the location done. Document the use of personal protective devices,
of all visible injuries and scars. If the patient consents, such as goggles, and hearing protection.
photographs may be included in the documentation
and should be identified by the patient’s name, date Oral Health
the photograph was taken, identity of the person taking According to the Centers for Disease Control and
the photograph, and setting in which the photograph Prevention (CDC), nearly one third of adults in the
was taken. United States have untreated tooth decay and 42%
of adults 30 years of age and older have some form
Safety Measures of periodontal disease; this increases to 70% in adults
Adults are at risk for injury resulting from motor vehi- 65 years of age and older. In addition, nearly one fourth
cle crashes; therefore, safety screening should include of all adults have experienced some facial pain in the
documentation of seat belt use and risky behavior while past 6 months. Oral cancers are most common in older
driving, such as drinking alcohol and use of cell phones. adults, particularly those older than 55 years of age who
If the patient rides a motorcycle or bicycle, inquire smoke and are heavy drinkers. Unfortunately, many
about helmet use. Consider safety in the home as well; adults do not get regular dental care. Documentation
ask the patient about and document the presence of related to oral health should include the number of
weapons or firearms, smoke detectors, and any safety dental caries, identification of missing or broken teeth,
equipment such as grab bars in a tub or shower area. condition of the patient’s gums, and the patient’s personal
If the patient has a pool, document the presence of a oral hygiene habits, such as the frequency of brushing
fence around the pool and a pool alarm. In instances and flossing and use of fluoride toothpaste.
of water recreation or sports, document the patient’s
use of sunscreen, personal flotation devices, and eye Blood or Blood Product Transfusions
protection. Although blood or blood product transfusions are rarely
administered in an ambulatory care setting, there are
Occupational History health risks associated with having had transfusions and
The U.S. Congress created the Occupational Safety so any past transfusions should be documented in the
and Health Administration (OSHA) in 1970. Its patient’s record. Document the date, type of product
mission is to prevent work-related injuries, illnesses, transfused (e.g., whole blood, packed cells, fresh-frozen
and occupational fatalities by issuing and enforcing plasma), number of units transfused, and the reason.
standards for workplace safety and health. OSHA’s Document whether there were any complications from
role is to ensure safe and healthful working conditions. the transfusion.

Risk Factor Identification Based or disease screening for populations identified as high
on Family History risk. If the patient’s history is positive for any of these
familial-tendency conditions, it is important to educate
Obtaining a detailed family history enables you to assess
the patient that he or she has these nonmodifiable risk
risk due to the complex interactions of genes, lifestyle,
factors. The more nonmodifiable risk factors a patient
and exposures experienced by family members as well
has, the more important it is that the patient reduce risk
as susceptibility due to single genes. Conditions known
by controlling those risk factors that can be modified.
to have a genetic familial tendency include diabetes,
Documentation should reflect the education provided
cardiovascular disease, hypertension, hyperlipidemia,
initially, and you should document any progress toward
certain types of cancer, asthma, and osteoporosis.
risk modification at subsequent visits.
Establishing genetic risk factors may enable an ear-
Assessing family history as part of risk stratification
lier or more accurate diagnosis and allows you and
is a key initiative of the CDC and HHS. The CDC
your patient to determine the degree of intervention
tool is Family Healthware, an interactive, Web-based
needed, such as preventive measures, surveillance, or
tool that assesses familial risk for six diseases (coronary
management. It is common practice to inquire about
heart disease; stroke; diabetes; and colorectal, breast, and
the medical history of parents, siblings, and grandpar-
ovarian cancer) and provides a “prevention plan” with
ents; however, there are several hereditary conditions
personalized recommendations for lifestyle changes
that require information about multiple generations to
and screening. This tool can be accessed at www.fam-
understand various inheritance patterns, such as with
ilyhealthware.com/consumer. If a patient completes
certain cancers. At a minimum, documentation of the
the screening and is found to have risk for any of the
family history should include the age, health status, and
diseases, document which disease(s) and the prevention
presence of diseases of first-degree relatives, defined as
plan that is implemented.
parents, grandparents, and siblings. Document the age
“My Family Health Portrait” was developed by HHS
of the relative, presence of any conditions that have a
through the Office of the Surgeon General. Part of this
genetic or familial tendency, and current health status
initiative is to encourage discussion among family mem-
of the individual. You should document age and cause
bers about their health history. The tool helps patients
of death for deceased relatives. It may be necessary to
assemble and organize family history information and
remind the patient that a family history is only pertinent
makes a pedigree, which then the patient can print and
for blood relatives, not spouses, in-laws, or people who
present to his or her health-care provider. It does not
are adopted. When a person who is adopted is unaware
offer medical advice or screening recommendations.
of his or her family history, this should be documented
The tool is accessible at https://familyhistory.hhs.gov.
to alert the health-care team that the patient may be at
If the patient brings in a printed report, you should
risk for any genetic conditions. If the family history is
incorporate it into the medical record. You should discuss
positive for any genetically transmitted traits or con-
the results with the patient, and you should document
ditions, documentation may include a pedigree chart,
if any action is indicated, such as additional screening.
using standard symbols to depict inheritance patterns.
There are certain findings from the family history
that are particularly important to document. These Risk Factor Identification Based
include early age at onset, two or more first-degree on Screening Tests
relatives with the same disorder or related conditions, The U.S. Preventive Services Task Force (USPSTF) is
a family member with two or more related conditions, mandated by Congress to conduct rigorous reviews of
disease occurring in the sex affected less often, and scientific evidence to create evidence-based recommen-
conditions that are refractory to usual treatment or dations for preventive services that may be provided
prevention strategies. These are considered “red flags” in the primary care setting. Since its inception, the
in the family history and indicate a higher level of risk USPSTF has made and maintained recommendations
for family members. Algorithms have been created for on dozens of clinical preventive services that are in-
certain diseases, such as coronary artery disease (CAD) tended to prevent or reduce the risk for heart disease,
and CVA, which consider these characteristics and cancer, infectious diseases, and other conditions and
stratify family history into three risk categories (weak, events that impact the health of children, adolescents,
moderate, and strong). Recent literature is filled with adults, and pregnant women. The task force assigns each
studies evaluating statistical models that predict risk recommendation a letter grade, as shown in Table 6-1,
for disease or some other adverse event. The purpose based on the strength of the evidence and the balance
of a risk prediction model is to stratify individuals of benefits and harms of a preventive service. The task
accurately into risk categories that are clinically rele- force does not consider the costs of a preventive ser-
vant. This risk information can be used to guide clinical vice when determining a recommendation grade. The
decision-making about preventive interventions for people recommendations apply only to people who have no

Table 6-1 USPSTF Grade Recommendations

Grade Definition Suggestions for Practice
A The USPSTF recommends the service. There is high Offer or provide this service.
certainty that the net benefit is substantial.
B The USPSTF recommends the service. There is Offer or provide this service.
high certainty that the net benefit is moderate or
there is moderate certainty that the net benefit is
moderate to substantial.
C The USPSTF recommends selectively offering or Offer or provide this service for selected patients
providing this service to individual patients based depending on individual circumstances.
on professional judgment and patient preferences.
There is at least moderate certainty that the net
benefit is small.
D The USPSTF recommends against this service. There Discourage the use of this service.
is moderate or high certainty that the service has
no net benefit or that the harms outweigh the
benefits.
I The USPSTF concludes that the current evidence is Read the clinical considerations section of the USPSTF
insufficient to assess the balance of benefits and Recommendation Statement. If the service is offered,
harms of the service. Evidence is lacking, of poor patients should understand the uncertainty about the
quality, or conflicting, and the balance of benefits balance of benefits and harms.
and harms cannot be determined.
signs or symptoms of the specific disease or condition to as a well-woman examination (WWE), the visit
under evaluation, and the recommendations address includes focus on the gynecological history (including
only services offered in the primary care setting or sexual history and IPV screening, as discussed earlier)
services referred by a primary care clinician. The most for women of childbearing age as well as education
up-to-date version of the recommendations, as well as about menopause and postmenopausal health concerns
the complete USPSTF recommendation statements, when appropriate. In addition to a standard physical
are available along with their supporting scientific examination, a clinical breast examination and pelvic
evidence at www.USPreventiveServicesTaskForce.org. examination should be performed. Other screening
Some of the USPSTF recommended screening tests examinations, such as those shown in Table 6-3, may be
that are appropriate for the general adult population clinically indicated. Your documentation should reflect
are shown in Table 6-2. what screening is done. If a recommended screening is
Various specialty societies, such as the ACS and the not performed, document the rationale.
AHA, and government agencies, such as the CDC, also Screening for STDs and gynecological cancers is
publish recommendations for screening tests. Insurance part of the pelvic examination. Obtain a Papanicolaou
companies may have their own recommended screening (Pap) test to screen for cervical cancer. Bimanual pelvic
tests. Many EMR systems will alert health-care providers examination should be performed to assess the uterus
when an age-related recommended screening test is due and search for any adnexal masses. It is important to
and may help track results of screening tests. It is beyond document whether there is any difficulty performing
the scope of this book to discuss all the screening tests any part of the pelvic examination. Certain patient
that could be performed; determining which screening characteristics may lead to a clinically unsatisfactory
tests to order is based on conditions and diseases for examination. Rather than simply omitting the part of
which the patient is at risk as revealed by the personal the examination that was difficult or unsatisfactory,
medical and social history and family history. you should document the difficulties encountered and
describe why the examination was unsatisfactory. If a
Gender-Specific Screening patient refuses any part of the examination or refuses
to have a screening test that is indicated, you should
Screening for Women document the patient’s refusal in the appropriate sys-
In addition to the history and physical examination that tem (i.e., if the patient refuses the rectal examination,
you will perform for all adult well visits and the screen- document in the genitourinary system) or in the plan
ing recommendations outlined in Table 6-2, the female if a recommended test is refused. Your documentation
preventive care visit typically includes additional risk should record the findings of all screening tests and
assessments, screening, and counseling. Often referred that you discussed the results with the patient.

Table 6-2 USPSTF Screening Recommendations for Common Conditions

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 6-3 Screening Recommendations for Women

Assessments, Screenings, and Counseling Recommendations*
BRCA risk assessment and genetic counseling/ Risk assessments for women with a family history of breast, ovarian,
testing 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 FDA-approved contraceptive methods, sterilization procedures,
methods 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.
Preconception Care with specific characteristics and medical conditions.

Given that nearly one half of pregnancies are unintended, Your documentation should include the options for
preconception care should be considered an integral part contraception that were discussed, risks and benefits
of primary care for women of reproductive age. Common of each option, any specific monitoring needed for
issues in preconception care include family planning, any particular option, and which option the patient
nutrition, achieving a healthy body weight, screening and chose. You should encourage both women and men to
treatment for infectious diseases, assessing immunization develop a reproductive life plan, including individual
status and vaccinating when indicated, and reviewing goals about childbearing and a plan for achieving them.
medications for teratogenic effects. Control of chronic Reproductive life planning tools are available at www
diseases is essential for optimizing pregnancy outcomes. .cdc.gov/preconception/reproductiveplan.html.
You should consider asking all women of reproduc- A patient’s weight and BMI should be recorded at
tive age about their intention to become pregnant, and every visit, but it is especially important to document
then provide contraceptive counseling tailored to each for those patients who are considering or planning to
patient’s intentions. The CDC’s criteria for contraceptive become pregnant. All women with BMI below 19.8 kg/m2
use can assist in counseling patients about contracep- or above 26 kg/m2 should be counseled about the short-
tive choices, and it provides evidence-based guidance and long-term risks to their own health and the risks to
on the safety of contraceptive methods for women future pregnancies, including infertility. Women who

are underweight have higher risks of preterm birth (less inguinal hernia check as well as the general physical
than 37 weeks estimated gestational age [EGA]), low- examination. In patients 18 to 30 years of age, perform
weight birth (less than 2,500 g), and intrauterine growth a testicular examination to screen for testicular cancers.
retardation. Women who are overweight or obese are A prostate and rectal examination should be performed,
at risk of diabetes, gestational diabetes, hypertension, as indicated in Table 6-4. Test the stool for occult blood
fetal malformation, fetal macrosomia, increased cesarean as part of screening for colorectal cancer. Guidelines
delivery rate, and intrapartum and operative complica- for prostate-specific antigen (PSA) as a screening for
tions. Documentation should reflect that you educated prostate cancer are controversial. In 2013, the American
any patients who are under- or overweight on the ideal Urological Association (AUA) announced updated
body weight as well as risks associated with their weight. guidelines indicating that screening in men below
Control of chronic disease is one of the most import- 40 years of age is not indicated. Routine screening in
ant aspects of preconception care. For any patient who men between 40 and 54 years of age at average risk
indicates a desire to become pregnant, you should screen is not recommended. For men from 55 to 69 years of
for diabetes, hypertension, seizure disorder, and use of any age, the decision to undergo PSA screening involves
medication that may have teratogenic effects. It is beyond weighing the benefits of preventing prostate cancer
the scope of this book to address control of these diseases, mortality in one man for every 1,000 men screened over
but your documentation should reflect that you educated the a decade against the known potential harms associated
patient on the importance of controlling these conditions. with screening and treatment. For this reason, shared
Screen patients who wish to become pregnant for STIs decision-making is recommended for men 55 to 69
and other communicable diseases as indicated. Update years of age who are considering PSA screening and
vaccines as needed. As discussed previously, screening for proceeding based on patients’ values and preferences.
use or abuse of tobacco, alcohol, and other substances as Routine PSA screening is not recommended in men over
well as IPV should be part of the preventive care visits for 70 years of age or for any man with less than a 10-year
every patient of reproductive age. Documentation should life expectancy. Your documentation should indicate
reflect what screening is done, any problems or concerns which guidelines you followed as well as any discussion
identified, and a plan to address each. about PSA screening and shared decision-making that
you had with the patient.
Screening for Men If the patient refuses to allow any part of the exam-
The male preventive health visit, also called the well-man ination, document the refusal as well as any education
examination, should include a genital examination and provided to the patient on the importance of the
Table 6-4 Screening Recommendations for Men

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 Discuss the risks and benefits of screening with DRE and PSA beginning at age
counseling 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 Inconsistent use of condoms, new or multiple sex partners, history of and/or
counseling 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.

examination component that was refused. Your docu- customized to a particular practice setting or specialty.
mentation should record the findings of all screening When handouts are given, document the content, and
tests and that you discussed the results with the patient. then ask follow-up questions at the next visit and de-
termine whether the patient has any related questions.
MEDICOLEGAL ALERT ! Assessing Vaccination Status

Review of vaccination status is an important component
If any part of the examination is deferred, document the of the adult health maintenance visit. Vaccines are used
reason so that readers of the medical records will not to prevent disease, and there are several that should be
have to speculate. Deferral implies that the examination maintained through adulthood. Many patients are not
is not done at this time for a specific reason. “Deferral” aware of the need for vaccines unless they are required
should not be documented if the patient is actually for certain activities, occupations, or college entrance.
refusing a recommended examination or test. If the If the patient was fully vaccinated during childhood,
patient refuses, educate the patient on the importance then vaccines that they are likely to need as adults
of performing the examination or test; if the patient include diphtheria-tetanus, hepatitis B, herpes zoster,
persists in refusing, you should respect his or her right to HPV, varicella, influenza, and pneumonia. If the patient
refuse, but document any education provided and the was not fully vaccinated during childhood, a catch-up
risks associated with refusing the examination or test. 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.
Health Education and Counseling
According to the latest National Ambulatory Medical
Care Survey (2013), health education and counseling Summary
were documented as being ordered or provided at
37.2% of office visits. The most frequent education or Adult preventive care visits provide an opportunity to
counseling provided was related to diet or nutrition and assess risk for acquiring certain medical conditions.
exercise. The preventive health visit is a convenient time Documentation of identified risk factors from personal
to educate and counsel patients. Any patient education history, family history, and lifestyle choices is a key
or counseling should be specifically documented. It is component of the visit. Many tools are available to assist
important to reinforce and praise patients for positive you with screening and assessing risk factors. Alerts in
health behaviors and equally important to educate patients an EMR system can prompt you to complete screening
about the risks associated with negative health behaviors, tests and to track the results. Guidelines published by
such as tobacco use or sedentary lifestyle. Studies have governmental or specialty organizations also can help
shown that the health-care provider’s advice can have you determine which diagnostic screening tests should
a strong influence on patient behavior. Patients may be done and at what ages the screening should take
not be ready to change their behavior at any particular place. Although differences in the guidelines exist, the
visit, but they may move closer to making a change intent of the guidelines is to encourage discussion and
when the information is reinforced over multiple visits. shared decision-making between you and each of your
It is highly recommended that you provide educa- individual patients. Every visit is an opportunity to as-
tional information in writing when possible. This not sess vaccination status and to provide health education
only serves to reinforce information that was given and counseling. Detailed documentation of what was
verbally but also gives patients information that they discussed is an essential part of the adult preventive care
can read at their own pace and at a time that is conve- visit. To reinforce the content of this chapter, please
nient for them. Many professional organizations offer complete the worksheets that follow. And be sure to
patient handouts on common conditions. Resources are review Appendix A, the Document Library, for full
available in print and electronically, and many can be case examples of patient documentation.

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.


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.


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.


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.


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?


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?


Worksheet 6.5
Name
Abbreviations
of this chapter.
ACS AHA
AHRQ AUA
AUDIT BMI
CAD CDC
CTS CVA
DAST-10 EGA
EMR ENDS
FDA HHS
HPV IPV
NIDA-Modified ASSIST OSHA
PID PPD
PSA STD
STI USPSTF
WWE

Chapter 7
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.
as presented in Chapter 2. The approach to the history and

Introduction physical examination, however, should be specific to older
adults, and many assessments will rely on both history
People older than 65 years of age are frequent consumers
and examination. Patient-driven assessment instruments,
of health-care services. It is estimated that older adult
such as the Geriatric Health Questionnaire (developed
visits will comprise at least 30% of all visits in a typical
by Gerald Jogerst, MD) shown in Figure 7-1, are often
primary care outpatient practice (Elsawy and Higgins,
used. Asking patients to complete questionnaires and
2011). Older adults may present with any combination
perform specific tasks not only saves time but also provides
of nonspecific, apparently unrelated, and seemingly trivial
useful insight into their motivation and cognitive ability.
complaints. Sometimes they have no complaint at all.
To the extent that patients are unable to complete the
Many older patients interpret their pain or dysfunction
assessment themselves, you can rely on traditional patient
as “normal” signs of aging and it would not occur to
interviews that may involve input from a family member
them to seek medical attention for such complaints.
or other caregiver. You should follow up on any abnor-
They may visit a health-care provider simply to mollify
mal responses to screening questionnaires with further
a spouse or child. Alternatively, the older adult patient
testing or interventions or more in-depth instruments as
may have multiple comorbid conditions and multisystem
indicated. An important part of risk assessment screen-
disorders, and the focus of the visit is managing these
ing of older adult patients is to review the medication
conditions, leaving little time for preventive care and
history. Other risk factors that are typically assessed
screening assessments. For older patients with many
through history taking are related to functional ability;
concerns, the use of a “rolling assessment” over several
socioenvironmental factors, such as living environment
visits should be considered. The rolling assessment targets
and nutrition; physical health, including sensory deficits
at least one domain for screening during each office visit.
and mobility; and mental health status.
Medication Use
Assessing Older Adult Risk Review the patient’s medications at every visit. A care-
Factors Through History Taking ful determination should be made as to the merits of
continuing each medication as well as prescribing any
The assessment of an older adult patient incorporates all new medications. If any medications are discontinued,
facets of a comprehensive history and physical examination document the date and the reason why. If medications
153

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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Chapter 7 Older Adult Preventive Care Visits | 155
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: _______________
Figure 7-1 Geriatric Health Questionnaire. (From Rakel D. Textbook of Family Medicine. 7th ed.
Philadelphia, PA: Saunders; 2007.)
are added or if dose adjustments are made, document the EXAMPLE 7.1
indication. Special consideration should be given to the E.P.’s urine culture showed infection with multidrug
possibility of drug–drug and drug–disease interactions; resistant E. coli. The only effective oral antibiotic is
most electronic medical record (EMR) systems feature nitrofurantoin, which is identified by Beers criteria as
alerts that will notify the provider of such interactions. a medication that is potentially inappropriate. All other
The Beers criteria, published by the American Geriatric effective antibiotics would require parenteral admin-
Society (AGS), include lists of potentially inappropriate istration. E.P.’s most recent blood work demonstrates
medication to be avoided in older adults. The 2015 estimated glomerular filtration rate greater than 50%,
update includes lists of select drugs that should be so she is not likely to have accumulation effects due to
avoided or should have their doses adjusted based on an inadequate excretion. She does not have any pulmonar y
individual’s kidney function. The update also includes disease. I discussed the culture results and treatment
select drug–drug interactions that were documented to options with E.P. and she would prefer to take oral
be associated with harm in older adults. Unfortunately, medication rather than intravenous. A prescription
the criteria have sometimes been misinterpreted and was sent to her pharmacy for standard 10-day course
misused. The potentially inappropriate medications are of nitrofurantoin.
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 To become more familiar with the Beers criteria,
rationale for doing so as shown in Example 7.1. complete Application Exercise 7.1.
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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.

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.
Functional Impairment Katz Index. The Lawton IADL instrument is most

Assessment of functional impairment should be docu- useful for identifying how a person is functioning at
mented as part of the older adult’s history, typically as the present time and for identifying improvement or
part of the social history and/or the review of systems. deterioration over time. It measures eight domains of
Additional screening will be done as part of the physical function. Women are scored on all eight areas of func-
examination. Functional impairment is defined as diffi- tion; historically, for men, the areas of food preparation,
culty performing or requiring the assistance of another housekeeping, and laundering are excluded. Patients are
person to perform activities of daily living (ADLs) and scored according to their highest level of functioning
instrumental activities of daily living (IADLs). You in each category. Scores range from 0 to 8 for women,
should establish a baseline of the patient’s ability to and 0 to 5 for men; the higher the score, the greater the
perform these tasks at about 65 years of age, but you person’s level of independence. Deficits in the ADL or
may do it earlier if indicated by the presence of chronic IADL can signal the need for problem-specific physical
disease or significant morbidities. Documentation of examination, more in-depth evaluation of the patient’s
the type of screening done and the results of screening circumstances, and the need for additional assistance.
provides a benchmark against which to measure future
levels of function and to determine the need for support Nutrition
services or placement (e.g., in an assisted living facility Aging is accompanied by physiological changes that can
or nursing home), for medical or surgical interventions negatively affect nutritional status. Sensory impairments
(e.g., total hip or knee replacement), or for rehabilitative that occur with aging, such as decreased sense of taste
services (e.g., occupational or physical therapy). Two and smell, may result in decreased appetite. Poor oral
commonly used tools to screen patients and document health and dental problems can lead to difficulty chewing,
their functional ability are the Katz Index of ADLs and inflammation, and a monotonous diet that is poor in quality,
Lawton IADL Scale. The Katz Index ranks adequacy all of which increase the risk for malnutrition. Progressive
of performance in the six functions of bathing, dressing, loss of vision and hearing, as well as osteoarthritis, may
toileting, transferring, continence, and feeding. Patients limit mobility and affect an older adult’s ability to shop
are scored yes/no for independence in each of these six for food and prepare meals. Energy needs decrease with
functions. A score of 6 indicates full function; 4 indicates age, yet the need for most nutrients remains relatively
moderate impairment; and 2 or less indicates severe unchanged, resulting in an increased risk for malnutrition.
functional impairment. The Lawton IADL Scale is an Nutritional assessment for older adults is accomplished
appropriate instrument to assess independent living skills, by history taking, physical examination, and may include
such as the ability to use the telephone, go shopping, select laboratory tests if indicated. One useful screening
prepare food, do laundry, practice housekeeping, handle tool for obtaining a nutritional history is the Nutritional
finances, have responsibility for one’s own medication, Health Checklist, shown in Figure 7-2. Another tool is the
and provide transportation. These skills are considered Mini Nutritional Assessment—Short Form (MNA-SF),
more complex than the basic ADLs measured by the which provides an easy way to screen older adults for

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

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malnutrition in less than 5 minutes. The form consists physical and mental health. Hearing loss inhibits the
of six questions and has been validated as an efficient ability to interpret speech. This, in turn, may reduce
screening tool. The score for screening is derived from a patient’s ability to communicate, which can result
six components—reduced food intake in the preceding in social isolation, depression, and anxiety and can
3 months; weight loss during the preceding 3 months; pose environmental safety issues, such as the inability
mobility; psychological stress or acute disease in the to hear warning alarms or someone knocking on the
preceding 3 months; neuropsychological problems; and door. The United States Preventive Services Task Force
body mass index (BMI). The MNA-SF has predictive (USPSTF) currently recommends screening older adults
validity for other components, including adverse health for hearing impairment by periodically questioning
outcome, social functioning, and rate of visits to the general them about their hearing, counseling them about the
practitioner as well as length of hospital stay, likelihood availability of hearing aid devices, and making refer-
of discharge to a nursing home, and mortality. The com- rals for abnormalities when appropriate. The optimal
plete tool and scoring criteria may be accessed at www frequency of such screening has not been determined
.mna-elderly.com. Positive findings in the history should and is left to the clinician’s discretion.
prompt further assessment with physical examination. The Hearing-Dependent Daily Activities (HDDA)
Scale is shown in Figure 7-3. It is a rapid and easy method
Sensory Deficit Screening of assessing the impact of hearing loss on daily life. This
Hearing loss is the third most prevalent chronic condi- scale has been shown to correlate well with pure tone
tion in older adults and has important effects on their audiometry, which is the standard test for assessment of
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 Always Occasionally Never
1. Have you noticed that you don’t hear as well as you used to?
2. Has anybody told you that you don’t hear well?
3. Does your family tell you that you turn up the volume of the television or radio
very loudly?
4. When you’re talking to someone, do you have to ask the person to speak
louder?
5. When you’re talking to someone, do you have to ask the person to repeat
what they’re saying various times?
No, I With Some Yes,

Can’t Difficulty Without
Difficulty
6. Can you understand when someone is speaking to you in a low voice?
7. Can you understand when someone is speaking to you on the telephone?
8. Can you hear the sound of a coin dropping on the floor?
9. Can you hear the sound of a door closing?
10. Can you hear when someone approaches you from behind?
11. 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?
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.)

hearing loss. Patients are asked 12 questions about their history of all older adults. Four risk factors have been
level of hearing and understanding. Each question has identified as common to these syndromes:
a range of three possible answers. The lower the score,
1. Older age
the greater the impact of hearing loss on the patient’s
2. Functional impairment
daily activities. If you identify a hearing deficit through
3. Cognitive impairment
history taking, then the physical examination should
4. Impaired mobility
include specific measures to assess hearing.
Visual deficits can dramatically impact a person’s Three of these four factors are amenable to intervention;
mobility and other essential functions, such as meal therefore, it is imperative that you assess your older
preparation or medication management. As part of adult patients for these risk factors. Documenting the
the review of systems, document if there have been any presence or absence of these risk factors, and a treat-
changes in vision, date of last vision testing, presence ment plan to address each one, should be part of every
or absence of eye discomfort or pain, excessive tearing, preventive care visit for the older adult.
or blurred vision. Falls are a significant cause of morbidity and mortal-
ity, occurring in 30% of adults over 65 years of age and
Mental Health Screening 40% over 80 years of age; therefore, the focus should
Depression is common in older adults and may go un- be on preventing falls. Environmental factors that can
detected unless specifically screened for. If the patient help prevent falls include adequate lighting, use of
gives a positive response to either of the following two grab bars or assistive devices such as canes or walkers,
questions, further inquiry is needed: a clutter-free environment, and removing throw rugs
or having nonskid backs on all rugs. If there are pets
• Over the past month, have you often been both- in the house, patients should be alert to their location
ered by feeling sad, depressed, or hopeless? to avoid tripping over them. Nonenvironmental factors
• During the past month, have you often been that may cause falls include decrease in vision; lack of
bothered by little interest or pleasure in doing flexibility; loss of muscle strength, especially in the
things? legs; and changes in sleep patterns. Other important
The Geriatric Depression Scale (GDS) is designed risk factors for falls in older adults are medication use
specifically to screen for depression in older adults. The and chronic health conditions. High-risk medications
GDS questions are answered yes or no. This simplicity include calcium channel blockers, analgesics, sedatives,
enables the scale to be used with individuals who are ill and hypnotics. If a patient has been prescribed any of
or moderately cognitively impaired. Two different scales these medications, make sure he or she is educated on
are available: a long form that contains 30 questions the potential risk, and the education that you provide
and a short form that contains 15 questions. Either should be documented. Conditions such as heart disease,
form may be used as part of a comprehensive geriatric peripheral vascular disease, neuropathies, and bladder
assessment. The scoring for the long form, shown in incontinence also can increase the risk for falling.
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 Assessing Older Adult Risk
“normal,” 5 to 7 “mildly depressed,” 8 to 11 “moderately
depressed,” and 12 to 15 “severely depressed.” Factors Through Physical
Geriatric Syndromes
Examination
The term geriatric syndrome has been defined by Inouye The physical examination of the older adult follows the
and colleagues (2007) as “multifactorial health conditions standard head-to-toe approach. Positive findings from
that occur when the accumulated effects of impairments the history will help guide the physical examination. The
in multiple systems render an older person vulnerable general assessment is important to establish an overall
to situational challenges.” The term is used to capture sense of the patient’s health status and global functioning.
those clinical conditions in older people that do not fit You should document the patient’s height, weight, and
into discrete disease categories and include conditions BMI at every visit, along with standard vital signs. If
such as functional decline, falls, delirium, frailty, pressure the patient has any chronic medical problems, such as
injuries, and urinary incontinence. These syndromes cardiovascular disease or arthritis, you should examine
represent common, serious conditions for older people, the corresponding body system(s) and document your
holding substantial implications for functioning and findings. Other specific screening recommendations
quality of life, and should be assessed as part of the for older adults are presented.

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
5. no 15. no 25. yes
7. no 17. yes 27. no
9. no 19. no 29. no
10. yes 20. yes 30. no
Scale
0–9 Normal range
10–19 Mild depression
20–30 Severe depression
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.
Sensory Examinations the United States, is recommended for all patients

The prevalence of visual and auditory impairment who are 60 years of age and older. Patients at higher
is high in the older adult and may contribute to an risk (African Americans and those with a family
individual’s inability to function independently and in history of glaucoma) should start regular screening
a safe manner. You should check both near and distant at 40 years of age.
vision and refer the patient for further evaluation if If the history revealed any positive findings related to
corrected vision is greater than 20/40. Document the hearing changes, physical examination should include
presence or absence of cataracts as well as findings otoscopic examination because cerumen impaction is a
of fundoscopic examination. Regular screening for common reversible cause of hearing loss in older adults.
glaucoma, the second highest cause of blindness in Rinne and Weber tests may help distinguish between
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conduction and sensorineural hearing loss and may diagnostic criteria for dementia) in many people. For
prompt referral for further evaluation. scoring, one point is given for each recalled word. The
CDT is scored as either “normal” (patient places the
Balance and Mobility Assessment correct time and the clock appears grossly normal) or
Several tools exist to help determine a person’s risk for “abnormal” (incorrect time or abnormal clock). A score of
falling. One very simple test is the Timed Up and Go zero is positive for cognitive impairment. An abnormal
test. The score is recorded as the number of seconds it CDT with a score of 1 or 2 on the three-word recall test
took to complete the test and gives an assessment of is positive for cognitive impairment. A normal CDT
the patient’s mobility. Another tool is the Berg Balance and a score of 1 or 2 on the word recall test is negative
Test, which is a performance-based assessment tool that for cognitive impairment. You should incorporate the
is used to evaluate standing balance during functional completed CDT into the patient’s medical record, and
activities. The patient is scored on 14 different tasks, the patient’s serial drawings over time can be helpful
such as reaching, bending, transferring, and standing. in determining disease progression.
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 Additional Screening
quality of the performance of the task, whereas others
are evaluated by the time required to complete the task. National guidelines are established for routine screening
Scores for each item range from 0 (cannot perform) of older adults for certain conditions. The USPSTF
to 4 (normal performance). Overall scores range from recommendations for older adults include screening
0 (severely impaired balance) to 5 (excellent balance). for the following medical conditions, which is gener-
The Tinetti Performance Oriented Mobility Assessment ally accomplished through a combination of physical
tool is a test that evaluates both balance and gait. It starts examination and laboratory and other diagnostic tests:
with a component to measure balance, similar to the
Timed Up and Go test described earlier. In addition, • Abdominal aortic aneurysm
the patient’s gait is evaluated for step length and height, • Breast cancer
symmetry, and continuity. Other factors, such as trunk • Carotid artery stenosis
motion and walking stance, are included in the scoring. • Coronary artery disease
The score indicates the patient’s risk of falling as low, • Cervical cancer
medium, or high; the lower the score, the greater the • Colorectal cancer
risk of falling. Document the tool used and the score. • Osteoporosis
• Ovarian cancer
Cognitive Assessment • Peripheral artery disease
Dementia is a chronic, progressive loss of cognitive and • Thyroid disease
intellectual functions. Early screening for dementia A list of all USPSTF recommendations may be found
becomes more important with the advent of newer at www.uspreventiveservicestaskforce.org/Page/Name/
treatment regimens. The Mini-Cog test is a 3-minute topics-and-recommendations.
instrument to screen for cognitive impairment in older In addition to these screening tests, you should assess
adults in the primary care setting and can easily be in- the vaccination status of the older adult at every visit.
corporated into the physical examination. The Mini-Cog The Centers for Disease Control and Prevention (CDC)
uses a three-item recall test for memory and a simply regularly publishes recommended vaccination schedules
scored clock-drawing test (CDT). The latter serves as for older adults; the schedule may be viewed at www.
an “informative distractor,” helping to clarify scores cdc.gov/vaccines. When vaccines are given, document
when the score for memory recall is intermediate. The the date of administration, vaccine manufacturer and lot
Mini-Cog was as effective as or better than established number, and the name of the health-care professional
screening tests in both an epidemiological survey in a who administered the vaccine.
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
Pre-operative Evaluation
mini-mental state examination. The Mini-Cog is less of Older Adults
affected by patient ethnicity, language, and education and
can detect a variety of different dementias. Moreover, Although older adults are not the only ones who
the Mini-Cog is better at detecting only mild cognitive may need pre-operative evaluation, the percentage of
impairment (cognitive impairment too mild to meet peri-operative complications is higher in the older adult

population than in other age groups. The purpose of a and providing a baseline level, which can be helpful
pre-operative evaluation is not to “clear” patients for information postoperatively, particularly for surgeries
elective surgery but rather to evaluate and, if necessary, with potential hemorrhagic complications. Renal and
implement measures to prepare higher risk patients for liver function studies are not routinely needed but may
surgery. Pre-operative outpatient medical evaluation can be indicated for patients who have a medical condi-
decrease the length of hospital stay as well as minimize tion or medication use that would serve as indications
postponed or cancelled surgeries. To effectively provide for these tests. Pre-operative glucose determination
this service, you should understand the risk associated should be obtained because the presence of diabetes
with the particular type of surgery planned and relate increases peri-operative risks. Coagulation studies
this risk to the patient’s underlying acute and chronic (PT, INR, PTT) are not routinely indicated, because
medical problems. The complete evaluation should studies have shown that the yield is very low and that
include recommendations for evaluation and treat- abnormal results are expected or do not significantly
ment, including prophylactic therapies to minimize affect management. Coagulation studies are indicated
the peri-operative risk. Advanced age places a patient if the patient is receiving anticoagulant therapy or has
at increased risk for surgical morbidity and mortality a personal or family history that suggests a bleeding
because of increased likelihood of underlying disease disorder or has evidence of liver disease.
states. In one study (Ersan, 2015), the mortality rate Cardiopulmonary assessment may reveal key features
for patients older than 70 years of age undergoing that warrant pre-operative intervention or further
elective cholecystectomy was nearly 10 times that of evaluation, including elevated blood pressure, heart
younger patients. When age and severity of illness are murmurs, or signs of congestive heart failure or chronic
directly compared, severity of illness is a much better obstructive pulmonary disease (COPD). An ECG should
predictor of outcome compared to age. Emergency be obtained in patients older than 40 years of age or in
operations carry a greater risk compared to elective patients with a history of previously diagnosed coronary
operations in all age groups, particularly older adults. artery disease, any previous cardiovascular procedural
Diseases associated with an increased risk for surgical interventions or testing, current therapies, and any
complications include respiratory and cardiac disease, current symptoms suggestive of angina or congestive
malnutrition, and diabetes mellitus. Ideally you should heart failure. Patients in whom cardiac stress testing
evaluate the patient several weeks before the operation, was normal within the past 2 years or who have had
and you should manage any chronic diseases prior to coronary bypass surgery within the past 5 years, and
surgery. The history should include information about are without symptoms, require no further assessment.
the condition for which the surgery is planned, any Importantly, no pre-operative cardiovascular testing
past surgical procedures, and the patient’s experi- should be performed if the results will not change
ence with anesthesia. Document the presence of any peri-operative management (Zambouri, 2007). It is
chronic medical conditions, particularly of the heart beyond the scope of this text to address specific car-
and lungs. Make note of any medications (including diac conditions and pre-operative risk assessment for
over-the-counter medications). You may need to adjust each condition; further information may be obtained
drug dosages in the peri-operative period. Aspirin, non- from the American College of Cardiology/American
steroidal anti-inflammatory drugs, and anticoagulation Heart Association Guideline Update for Peri-operative
medications may need to be discontinued or have dose Cardiovascular Evaluation for Noncardiac Surgery
adjustment prior to surgery to avoid excessive bleeding. (Eagle et al, 2014).
Pre-operative laboratory and diagnostic studies once The major pulmonary complications in the peri-
routinely included a complete blood count (CBC), operative period are atelectasis, pneumonia, and bron-
comprehensive metabolic panel (CMP), urinalysis, chitis. Predisposing risk factors include cough, dyspnea,
prothrombin time (PT), international normalized ratio smoking, a history of lung disease, obesity, and abdominal
(INR), partial thromboplastin time (PTT), electrocar- or thoracic surgery. Chest x-rays may be helpful for
diogram (ECG), and chest x-rays. Numerous studies patients with these conditions, not only to screen for
have subsequently shown that most of these tests were active conditions but also to establish a baseline. You
ordered without a clear indication and that only a should evaluate patients with cough or dyspnea to identify
very small percentage of the results were unexpectedly the underlying cause of the symptoms. Advise patients
abnormal. Current recommendations call for fewer who smoke cigarettes to quit smoking for 8 weeks before
routine tests and for selective ordering of laboratory surgery to allow the mucociliary transport mechanism
tests based on specific indications. In addition, the to recover, the secretions to decrease, and the carbon
availability of previous laboratory testing can obviate monoxide levels in the blood to drop. You should treat
the need for pre-operative tests. A hemoglobin mea- any pulmonary infections pre-operatively. Pulmonary
surement is useful in detecting unsuspected anemia complications may be prevented by providing patients

with instructions on how to perform incentive spirom- planned and patient-specific health parameters to deter-
etry and deep-breathing exercises. mine the patient’s overall risk of developing postoperative
The decision to proceed with elective surgery begins complications. A written report can be generated, which
with an assessment of risk of developing postoperative you then can incorporate into the patient’s medical record.
complications. A Web-based risk calculator is available The risk calculator may be accessed at http://riskcalculator
from the American College of Surgeons (ACS) that .facs.org/RiskCalculator. To gain experience in using the
allows you to enter information about the type of surgery calculator, complete 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.

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.

Anticipating Future Needs A health-care power of attorney (POA) is a document

in which one person (the patient, or principal) names
Advance Directives another person (the agent, attorney-in-fact, or proxy) to
make decisions about health care. A POA differs from
Because of aging and often having multiple chronic a living will in that it focuses on the decision-making
conditions, the older adult has increased risk of process and not on a specific decision. The POA can
mortality. You should take advantage of outpatient cover a far broader range of health-care decisions.
visits to discuss with patients the different options The health-care POA is different from a durable
for end-of-life care and to understand what their POA, which authorizes someone to make financial
wishes are. Encourage your older adult patients to transactions for the principal; the health-care POA is
prepare advance directives, which are documents that specific to health-care decision-making. The health-
communicate a person’s wishes about health-care care POA can include a living will provision, but it
decisions in the event the person becomes incapable of should do so only as guidance for the agent rather than
making such decisions. Often, patients communicate as a binding selection. An ideal agent has the ability
their wishes to their health-care providers, but when to talk effectively with health-care providers and act
a person can no longer communicate sufficiently, as a strong advocate. The principal should discuss
another process for decision-making is needed. With the details of possible future medical choices with
the growing ability of medical technology to prolong the agent because the agent should be guided by the
life, decision-making about medical care is of great principal’s preferences. The law of each state prescribes
concern. Patients may have strong feelings that death the essential formalities for a valid POA for health
is preferable to perpetual dependence on medical care. Most states require two witnesses; a few permit
equipment or having no hope of returning to a certain notarization as an alternative. Forms specific to each
quality of life. Others feel just as strongly that heroic state are readily available from a variety of Internet
measures and technology should be used to extend sites. Once executed, a copy of the health-care POA
life as long as possible. document should be submitted to the health-care
There are two basic kinds of advance directives: living provider and made a permanent part of the patient’s
wills and health-care power of attorney. Both have medical record.
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
MEDICOLEGAL ALERT !
in a situation in which the directives are needed. Once
It is important to understand that a health-care POA
the decisions are made, the patient should complete the
is only in effect when a person lacks capacity to make
necessary forms and submit a copy to the health-care
his or her own decisions. There have been situations
provider so that it becomes a permanent part of the
where a spouse or an adult child of an older adult wants
patient’s medical record.
to make health-care decisions for a spouse or parent
A living will expresses a person’s preference for
who still has capacity. Sometimes, a family member or
medical care. In some states, the document is called
caregiver will ask a health-care provider to withhold
a directive to doctors or a declaration. Living wills
information from a patient, for instance, not telling a pa-
become effective only when the patient has lost capacity
tient that he or she has a cancer diagnosis. If the patient
to make health-care decisions and that patient has
still has capacity, withholding this information is inappro-
a particular condition, such as a terminal illness or
priate and could provide a basis for a legal challenge,
permanent unconsciousness. Specific issues usually
especially in the area of consent, because a patient must
covered in a living will include cardiopulmonary
have adequate information to make his or her own
resuscitation, mechanical ventilation, and artificial
decisions. If a health-care provider believes a patient
nutrition and hydration. Health-care providers often
to have capacity, the patient should be considered the
need to explain the details involved in each of these
decision maker. If a situation arises where a patient loses
issues so that the patient can make informed decisions.
capacity and there is no health-care POA document in
To be valid, a living will must comply with state law.
place and no court-appointed guardian with authority
A living will should be signed, dated, and witnessed
to make health-care decisions, then most states provide
by two people. Some states require a notary or permit
for a default surrogate decision maker in their state laws.
a notary in lieu of two witnesses. The executed living
Providers are responsible for knowing the laws of the
will should be kept as a permanent part of the patient’s
state in which they practice.
medical record.

Hospice and Palliative Care primary physician and can help with treatment of pain
Although not unique to the older patient, the need for and other symptoms, assistance with communication
care for noncurable or terminal conditions often arises regarding diagnosis and prognosis, support for patients
in this population; therefore, you should understand and families in medical decision-making and in navi-
the services that may be provided through hospice and gating the complex medical system, and emotional and
palliative care agencies. Hospice and palliative care spiritual support. Because palliative care services are
are very similar, and both focus on providing care and often delivered through a hospital, it is likely covered
comfort to patients who are dying. Most people have by regular medical insurance.
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
Summary
palliative care, but hospice is targeted care for those Care of the older adult presents unique challenges to
patients who are no longer seeking curative therapy. health-care providers. The responsibility of managing
For hospice services, a patient is generally considered complex and often multiple chronic diseases, along
terminal or within 6 months of death, and the referral with ongoing assessment of a variety of risk factors,
to hospice is often through the primary care provider. may seem overwhelming at times. It is helpful to use a
Hospice programs often rely on the family caregiver, rolling assessment approach with older adults, focusing
as well as a visiting hospice nurse, to provide services on a single domain of risk assessment at each visit. Risk
in the home or at an inpatient hospice facility. Most factor assessment is achieved primarily by taking an
hospice services concentrate on comfort rather than in-depth history. Positive findings from the history then
aggressive disease treatment for the patient who is direct you to areas of the physical examination that may
terminally ill. Insurance payments for hospice services need special attention. Many tools and references exist
vary greatly, and many hospice programs are covered to aid in providing timely screening and risk assessment.
under Medicare. Guidelines from many professional organizations are
Palliative care often fills the gap for patients who want also helpful in providing risk assessment. Discussions
and need comfort at any stage of any disease, and there about end-of-life care decision-making and what type
is usually no expectation that life-prolonging therapies of interventions a patient is willing to accept often
or aggressive treatment will be avoided. Palliative care take place with older adults and their family members
can be received by patients whether or not their illness is or caregivers. Documentation of the patient’s wishes
terminal, and such care focuses on providing relief from and intent helps to ensure that his or her wishes are
the symptoms and stress of a serious illness. The goal honored. Reviewing the worksheets that follow will
is to improve the patient’s quality of life. The majority help reinforce the contents of this chapter. And be sure
of palliative care is provided in an inpatient setting. to review Appendix A, the Document Library, for full
The palliative care team works in conjunction with the case examples of patient documentation.

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.


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.

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.”
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.


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 ADL
AGS BMI
CBC CDC
CDT CMP
COPD ECG
GDS EMR
IADL HDDA
MNA-SF INR
PT POA
USPSTF PTT

Chapter 8
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.
health-care providers or hospitals, information related

Introduction to advance directives, and documentation of telephone
and electronic communication with patients.
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 Components of the Medical
(ambulatory care) setting. Documenting the medical
encounter is just one component of a patient’s record; Record
other types of documents should be kept to ensure
continuity of care and to preserve information used Problem List
in overall patient management. A medical record To promote continuity of care by identifying key
is created for each p atient and should be arranged elements of the patient’s health history, information
in a consistent, uniform manner. The contents and from parts of the medical records is often summarized
organization of the record will vary depending on as a problem list, such as the one shown in Figure 8-1.
the needs of the practice and format (paper-based or The list is usually prominently displayed in the chart
electronic). Some providers may use forms such as a for easy access and reference. In an electronic medical
problem list, medication list, or flow sheet for some of record (EMR) system, the problem list may automat-
their patients. Patients may not always be compliant ically display when the record is opened. Problems
with recommended treatment or follow a provider’s are listed as either active or inactive. Active problems
recommendations. From a medicolegal standpoint, include current or chronic conditions that require
it is important to document noncompliance when it ongoing management or further workup. The date of
occurs. Other information that may become part of onset and the International C lassification of Diseases
the patient’s medical record includes demographic (ICD) code for each problem is usually documented.
and billing information, communication with other Inactive problems are those that occurred in the past
providers, results of laboratory or other diagnostic but are now resolved and can be either medical or
studies, immunization records, records from other surgical. It is important to update the list by entering
173

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:
1. Hospitalizations: Surgeries:
2. Date: Reason: Date: Reason:
3.
4.
5.
6.
7.
8.
9.
10.
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
Breast
Result
Pap/Pelvic Exam Date

Result
Mammogram Date
Result
Prostate/Testicular Date
Result
Date
PSA
Result
Colonoscopy/Sigmoid Date
Result
FOBT Cards Date
Result
CBC Date
Result
CMP Date
Result
Date
TSH
Result
Date
Total Cholesterol
Result
Date
HDL
Result
Date
LDL
Result
Date
Triglycerides
Result
Date
CXR
Result
Date
ECG
Result
Date
DEXA
Result
Figure 8-1 Sample form for health history with problem list. Author ISBN # Author's review
Sullivan 6662
Company. All rights reserved.
(if needed)
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Use the data from Figure 8-1, create a problem list for Mr. Jensen, and then compare it with the
problem list shown.
Problem list for Mr. Jensen.
Vernon Scott, MD, PC

Health History / Problem List
Name: William R. Jensen S.S.# - - Male X Adv. Directives Yes X No

DOB: March 30, 19XX Tel.# - - Fem G P Ab Organ Donor Yes X No
PROBLEM LIST ALLERGIES: PENICILLIN
1. Hypertension, diagnosed at age 53 Hospitalizations: Surgeries:
2. Dyslipidemia, diagnosed at age 58 Date: Reason: Date: Reason:
3. 1988 right rotator cuff repair
4. 1981 left inguinal herniorrhaphy
5.
6.
7.
8.
9.
10.
Social History Family History CANCER: colon
breast M
other
S M X 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
Breast
Result
Pap/Pelvic Exam Date

Result
Mammogram Date
Result
Prostate/Testicular Date
Result
Date
PSA
Result
Colonoscopy/Sigmoid Date
Result
FOBT Cards Date
Result
CBC Date
Result
CMP Date
Result
Date
TSH
Result
Date
Total Cholesterol
Result
Date
HDL
Result
Date
LDL
Result
Date
Triglycerides
Result
Date
CXR
Result
Date
ECG
Result
Date
DEXA
Result

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Initials
pertinent data as soon as they are received. For exam- had adverse reactions to any medications, such as a
ple, if a bone density report confirms the diagnosis of cough from an angiotensin-converting enzyme (ACE)
osteoporosis, then add this diagnosis to the problem inhibitor or severe nausea from codeine, document
list. Upon receiving a hospital discharge summary, any this information on the medication list as well. You
newly diagnosed conditions should be added to the list. may wish to include information about the patient’s
The organization and content of the problem list will insurance plan if use of a specific formulary is required.
vary depending on the needs of the practice or facility. In many EMRs, formulary information is built into
Refer back to the comprehensive history and physical the system and will alert you if a medication is not
examination shown in Figure 2-2 to complete Appli- covered by the patient’s insurance. It is convenient
cation Exercise 8.1. to include the name, location, and telephone number
for the pharmacy that the patient uses to fill prescrip-
Medication List tions; this information must be available if prescribing
A medication list provides a quick and easy format electronically. It is imperative that you review and
to document all the medications a patient is taking at update the medication list at every visit. In addition,
any given time. All prescription and nonprescription encourage your patients to maintain their own medi-
medications should be listed. It is important to include cation list because access to the record in your facility
herbal products, vitamins, minerals, dietary supple- may not always be possible. Many a pplications are
ments, or other regularly used over-the-counter (OTC) available for use on personal electronic devices, and
products. A comprehensive list will alert you to possible some include reminder alerts for when medications
drug–drug, drug–disease, or drug–herb interactions. It should be taken.
also will help to avoid duplication, such as prescribing
too many agents containing acetaminophen. The list
should include the name of the medication, indication, MEDICOLEGAL ALERT !
strength, and dosing directions, as shown in Figure 8-2.
You may wish to include the quantity written for and Although the medication list is helpful as a quick
number of refills authorized on the medication list in reminder of medications that a patient is taking, you
order to have this information easily located in one should never assume that it is a complete and accurate
place. (Prescription writing is covered in detail in record. Patients may start taking medications on their
Chapter 9.) This is helpful to office staff who may take own or because it was prescribed by another provider,
messages from patients or pharmacies requesting refills. or they may discontinue a medication and forget to tell
If a patient takes more than one prescription drug for you. It is your responsibility as the provider to determine
a condition, such as antihypertensive medications, it what medications the patient is taking at every visit
is helpful to list those medications together. When a before writing any prescriptions. You should specifically
medication is discontinued, it is helpful to document document “medication list reviewed” and the date of
the date and reason why directly on the medication list. the review; and if any discussion about medications
Make note of any medication allergies prominently in ensues, document that as well.
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 Refer back to the comprehensive history and physical
be included on the medication list or documented examination for Mr. William Jensen shown in Figure 2-2
as part of the past medical history. If the patient has to complete Application Exercise 8.2.

Chapter 8 Outpatient Charting and Communication | 177
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
Figure 8-2 Sample medication list.

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Using the blank form in Figure 8-2, complete a medication list for Mr. Jensen. Compare it with the completed form
shown.
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
Lotensin HCT 20/12.5 every a.m. 4/10/20XX HTN
Mevacor 20 mg 1w/evening meal 10/2/20XX dyslipidemia
Regular OTC Medication Dosage Frequency Reason
Supplements/Vitamins Dosage Frequency Reason

One-A-Day for Men 1 tablet daily general well-being
Fish oil supplement 1 tablet a.m. and p.m. CVD prophylaxis
08_Sullivan_Ch08.indd 178 Author ISBN # Author's review 7/3/18 6:26 PM

Flow Sheets billing information and any correspondence regard-

Many chronic medical conditions require regular ing billing and payment issues be kept separate from
monitoring of certain parameters. The frequency of clinical data.
monitoring depends on many factors, such as whether
the patient is stable or unstable or if a condition is Results of Laboratory Studies and Other
controlled or not controlled. For conditions in which Diagnostic Tests
monitoring of a laboratory test or some other param- Evaluation of a patient’s condition often requires ordering
eter is needed, a flow sheet is helpful. Flow sheets are laboratory tests, an electrocardiogram (ECG), imaging
commonly used to track results of coagulation studies, studies, and other diagnostic tests. Most EMR systems
such as the international normalized ratio (INR) and are designed to integrate with outside laboratories or
prothrombin time (PT) for a patient on anticoagulant other vendors that provide diagnostic testing so that
therapy, blood pressure readings of the patient with results are communicated from the vendor directly
hypertension, blood glucose and hemoglobin A1c into the patient’s medical record. Typically, there is
levels of patients with diabetes, and results of lipid some notification that a result is available for review,
studies of patients with dyslipidemia. Another use of such as an icon, a pop-up dialogue box, or notification
flow sheets is to track periodic interventions or treat- of a document in queue. In a paper chart, it is helpful
ments for certain conditions, such as a patient with to have a section of the medical record specifically
anemia who receives monthly vitamin B12 injections for the results of such tests. These are usually filed in
or a patient who receives Depo-Provera injections chronological order with the most recent results ac-
every 3 months for contraception. Figure 8-3 shows cessed first. Diagnostic imaging reports, rather than the
an example of a flow sheet that is used to monitor actual images, are usually kept in the patient’s record if
anticoagulation therapy. the images were done at another location. Even when
Often patients are asked to track certain results imaging studies are done on-site, the actual images are
at home, such as daily blood glucose monitoring or often stored in a separate location, and just the reports
recording blood pressure measurement. Applications are kept in the medical record.
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
Noncompliance With Medical
review results with the patient, be sure to document Treatment
this, because the results are on the patient’s device and
not always incorporated into the chart. Health-care providers are obligated to educate and
inform patients about their medical conditions, the
Demographic and Billing Information treatment options available, the risks and benefits of
It is necessary to collect some demographic infor- each option, and the risks and benefits of no treat-
mation about patients (Fig. 8-4). At a minimum, ment at all. Despite your best efforts, patients will
you should document the patient’s full legal name, not always follow your recommendations. There are
address, telephone number, and date of birth. If the many reasons why a patient may be noncompliant
patient is a minor, document who is authorized to with recommended treatment; some are unintentional
make health-care decisions for the patient. In the and some are intentional. Some unintentional barriers
case of a minor when the parents are unmarried or to compliance may be the patient’s culture, language,
divorced, it is prudent to document who is the custo- religious practices or beliefs, lack of insurance coverage
dial parent. Because of concerns about identity theft, for certain treatments, or other socioeconomic factors.
it is recommended that the patient’s Social Security You should make every attempt to identify barriers
number (SSN) not be used as an identification number and then assist the patient in becoming compliant if
or medical record number. Include the SSN in the the patient desires to do so. Even when fully informed
medical record only if it is needed for billing purposes about the possible consequences of noncompliance,
or another specific reason. patients may choose not to follow a recommended
Billing information is important to document in treatment plan.
the record. If the patient has insurance, identify the If a patient’s medical condition fails to improve, you
policyholder and his or her relationship to the patient. must determine why. Failure to improve could mean
Make a copy of the insurance identification card and that the patient has not been compliant with the recom-
keep it in the chart. It is generally recommended that mended treatment, the patient has not been diagnosed

Figure 8-3 Anticoagulant

flow sheet.
Copyright © 2019 by F. A. Davis Company. All rights
Sullivan reserved.
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7/3/18
Figure 8-4 Sample demographic screen in an EMR.
correctly, or the correct treatment has not been initiated. EXAMPLE 8.1
It is important to have a conversation with the patient, Noncompliance Note
and perhaps family members or caregivers, to determine S: M r. Graham, age 49, is here for follow-up on
whether noncompliance is a factor. Ask the patient h yper tension. He has not been taking the hydro-
whether he or she is taking any prescribed medication; if chlorothiazide 12.5 mg that was prescribed for
so, is the patient taking it appropriately? Has the patient him at the last office visit 2 weeks ago. He states,
instituted recommended lifestyle changes? Is the patient “I feel fine. I don’t need to take any medicine.” He
getting diagnostic tests done or going to therapy? Has deniesAuthor
chest pain, shor tness ISBN # of breath, Author's swelling
review
the patient consulted and followed up with the specialist? Sullivan
in theFig.
feet or ankles, 6662
visual changes,
(if needed)
or headache. OK Correx
After exploring these considerations, try to ascertain the He has
#
been counseled
Document name
on smoking cessation Date
F08_04 6662_C_F08_04.eps
patient’s understanding of the ramifications of noncom- but c ontinues
Artist to smoke Initials
Datea pack of cigarettes daily.
pliance. If the patient simply refuses to follow treatment AB
At the last visit, I recommended
03/06/18
Check if revision that he review
Editor's tr y to
recommendations, even when he or she understands e xercise
B / W 20 to 30 minutes 32nddays of the week,OKbutCorrex
color
X
the potential consequences of not following treatment, he hasFinalnot
4/C
(WidthiX
Size yet nitiated
2/C PMS
any exercise. His mother
Depth in Picas)
then the patient is considered to be noncompliant. You died of41p0 x 27p10at age 59, and his father
a stroke
Initials
died
Date
must document—in detail—the information discussed at age 51 from a myocardial infarction. He has a
with the patient, including the potential consequences younger brother with hyper tension that is con-
of continued noncompliance, as well as the patient’s re- trolled with medication.
sponse. “Noncompliance” should be documented in the O: M r. Graham is a well-developed, obese man,
assessment and on the problem list. The ICD-10 code NAD. He appears agitated.
Z91.19 may be used for noncompliance with medical VSHt: 6 ft 2 in.; Wt: 265 lb; BP right 168/102, left
treatment. Be sure to document in the plan portion any 172/104; T 98.2 orally; pulse is 94 and regular ;
advice or education that you provided. Example 8.1 r espirations 20 per minute.
demonstrates one way to document a noncompliance note.

Eyes: Pupils are round and reactive to light bilaterally.

Discs are sharp with normal cup-to-disc ratio. Fundi
Communication With Other
are unremarkable without AV nicking or exudates. Providers
Neck: No carotid bruits or JVD.
Hear t: RRR without murmur, clicks, or gallops. Nor- A referral is when one health-care provider advises the
mal S1 and S2. patient to see another provider. A referral to see a spe-
Chest: Breath sounds CTA all fields. There is no in- cialist may be required by the patient’s health insurance
creased AP diameter of the thorax. plan. Often, a referral or request for consultation is
Abdomen: Soft, nontender, no organomegaly or made when evaluation or management of a condition is
masses, physiological bowel sounds. beyond the scope of the referring provider’s training or
Extremities: No edema. Pedal pulses are 2+ and experience. The consultant’s role may be to recommend
equal bilaterally. further diagnostic testing, make a diagnosis, recommend
UA: Specific gravity 1.012, no proteinuria or a plan of treatment, or manage the patient’s condition,
hematuria. or a combination of these. To clarify the role of each
ECG: NSR without acute ischemic changes. provider, reference may be made to the referring provider
CXR: No active disease, no cardiomegaly. and the consulting provider. It is the referring provider’s
A: (1) Uncontrolled HTN, recently diagnosed. I10 responsibility to specify the reason for the referral and
(2) N oncompliance; patient has refused the action desired so that the consulting provider knows
t reatment up to this point. Z91.19 whether to provide an opinion only or to manage the
(3) Obesity with BMI of 34. E66.01 patient’s condition actively. Any information pertinent
(4) Tobacco use disorder. F17.200 to the referral should be transmitted to the consulting
P: H ad 15-minute discussion with patient regarding provider for review and may include a written summary,
hyper tension, its historical course with and with- progress notes, problem list, medication list, flow sheets,
out treatment, impor tance of taking prescribed test results, other consultants’ notes, and sometimes
m edication daily, and potential complications of hospital records. This communication between providers
nontreatment, including stroke, hear t attack, and helps to avoid duplicating tests that have already been
death. Discussed his personal and family risk fac- done or prescribing treatment that may have been tried
tors for these conditions. Also discussed HTN as previously but was not effective.
the “s ilent killer” and explained possible end-organ The primary care provider maintains responsibility for
damage despite not having symptoms or feeling bad. the overall health of the patient even when the patient
He stated his understanding and had no questions. is under a specialist’s care. Consulting providers are
He expressed reser vations about “star ting a pill that expected to communicate with the referring provider
I will have to take forever.” The medication is cov- in a timely manner. Patient authorization is not needed
ered by his insurance, so medication access is not for communication between providers; it is implied with
a barrier. He did agree to have the nurse at work the referral and necessary for continuity of care. The
check his blood pressure daily, and he will get the initial consultation note typically consists of a problem-
blood work done. He agreed to follow up here in 2 specific history; a problem-focused physical examination;
weeks but would not agree to star t the medication. impression or assessment; and recommendations for
care, management, or further workup. If the patient
is to remain under the care of the consulting provider,
MEDICOLEGAL ALERT ! then the consulting provider should keep the referring
provider updated periodically on the patient’s condition
It is crucial to document noncompliance in a patient’s
and response to treatment. Many EMR systems will
medical record. If it is not documented and the patient
automatically generate a letter that includes history of
has a poor outcome, the patient or a family member
present illness (HPI), pertinent past medical history
may file a malpractice suit against you, claiming that you
(PMH), examination findings, and assessment and plan;
were negligent or did not care for the patient appropri-
some systems allow users to customize a letter template.
ately. You must document that you counseled the patient
A comprehensive history and physical examination
about the medical condition, discussed the risks and
for Mr. William Jensen was provided in Figure 2-2.
benefits of the recommended and alternative treatment
Part of the plan for the visit was to refer the patient to
options, and warned the patient about potential mor-
Dr. Michael Bennett for colonoscopy and biopsy.
bidity and mortality complications. Whenever possible,
Figure 8-5 shows a letter from Dr. Scott to Dr. Bennett
use direct quotes from the patient. Refrain from making
requesting assistance in the workup of this patient.
any judgment statements about the patient; document
Figure 8-6 shows a letter from Dr. Bennett to Dr. Scott
objective observations only.
with the results of the workup.

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
Encl: 3
Figure 8-5 Referral letter to Dr. Bennett.
Prior Medical Records condition. In most instances, the admitting physician

will indicate that a copy of the records should be sent to
When possible, you should review medical records the primary health-care provider. At times, the patient
from other providers and specialists if they are available. may need to request a copy of his or her records from
These records may be invaluable in filling in details and the hospital and give them to the provider. Reviewing
providing insight into the patient’s past medical history, other records adds to the complexity of the evaluation
especially when the patient has a chronic condition of the patient, so you should specifically document
that requires ongoing care. It is particularly helpful to that outside records were reviewed to help support the
evaluate what treatments have been tried in the past billing level for evaluation and management.
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 Documenting Communications
results of prior laboratory tests or diagnostic studies for
comparison purposes. If a patient has been hospitalized, With Patients
it is helpful to have a copy of the admission history
and physical examination (discussed in Chapter 10) Telephone Communication
and the discharge summary (discussed in Chapter 12) Communication with patients frequently occurs outside
in the medical records. Especially in instances in which an office visit. Telephone communication is a common
the patient is managed by a hospitalist and not the means of exchanging information between patients
patient’s primary health-care provider, having access to and health-care providers. The scope of telephone calls
such documents helps to ensure continuity of care and extends beyond the basic call to the provider’s office
Author ISBN #
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often
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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,
Encl: 1
Figure 8-6 Consultation letter from Dr. Bennett.
for medical advice or are a means of providing other Each practice should develop protocols identifying
information, such as results of diagnostic tests. There- which calls must be directed to a health-care provider
fore, the conversation that occurs by telephone is still immediately, which calls may be returned later, and
an important part of the patient–provider relationship which calls may be handled by another professional
and, as such, is subject to documentation in much the or office staff. If members of the professional staff
same way as other medical visits. Medicare and many are authorized to give telephone advice, there should
private insurers do not reimburse for telephonic com- be written protocols to define the scope of the staff
munications. Some third-party payers will pay if the member’s authority to give such advice to minimize
calls are coded properly. A billable call can be initiated the likelihood of staff practicing medicine without a
only by an established patient or the patient’s guardian. license and outside their scope of training.
The conversation cannot be related to a face-to-face Some practices use a telephone call log to document
appointment that occurred within the past week or will every call. If used, such logs should be retained as long
happen within the next 24 hours or the next earliest as medical records are retained. Others may use spe-
available appointment. In other words, the call has to cific forms, such as the one shown in Figure 8-7, for
substitute for in-office care. The relevant Current Pro- documenting telephone calls. Regardless of how the
cedural Terminology (CPT) codes, which reflect the documentation is done, the same information should
number of minutes of medical discussion, for physicians be documented consistently. This includes the date
are 99441 (5 to 10 minutes), 99442 (11 to 20 minutes), and time of the call, patient’s name, name of caller and
and 99443 (21 to 30 minutes). The comparable codes relationship to the patient, the complaint, advice given,
for care provided by other health professionals are follow-up plan, and disposition. Be sure the advice
98966, 98967, and 98968. To increase the likelihood of is documented in detail, and, ideally, you should ask
payment, you must document the call like an in-person the caller to repeat it so you can verify that the caller
visit with notation of the time spent (Torrey, 2017). understood
Author the advice given.
ISBNFailure
# toAuthor's
documentreview may
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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)
Figure 8-7 Telephone call log form.
lead to liability related to failure to diagnose, delay of communication. Like other modes of communication,
treatment, improper treatment, failure to follow up, there are advantages and disadvantages to using e-mail.
and breach of confidentiality.
If you attempt to reach a patient by telephone but are Benefits of E-mail
unable to do so, document your attempts, including the One of the greatest advantages is the convenience for
date and time of each attempt. Before leaving messages patients and providers. A patient can send an e-mail
on an answering machine or with someone other than and receive a response without staying on hold or wait-
the patient, ensure that consent has been obtained from ing by the telephone. Patients believe that requesting
the patient. The consent should indicate specifically if prescription refills, obtaining routine test results, and
and with whom messages may be left. Document in the scheduling appointments by e-mail saves time (Rajecki,
patient’s record that a message was left. Never leave clinical 2009). Zhou and colleagues (2007) found that the use of
information or advice as a voice message; instead, leave e-mail and electronic messaging decreased the amount
your name and a telephone number and request a call back. of time that providers spent on the telephone. Another
advantage is that e-mail creates a documentation trail
Electronic Mail that can be used to record activity and conversation,
Telephone communication between health-care provider providing a transcript of all that is said and not said,
and patient is not without its frustrations. Providers often in an electronic format.
view calls as unnecessary interruptions. Patients express
frustration that they may have to wait to receive a call Concerns Regarding E-mail
back from the provider. Several studies have shown that There are perceived and real disadvantages to using
patients would prefer communicating with providers by e-mail. One of the disadvantages that is cited most
electronic mail (e-mail); in one study (Stouffer, 2008), frequently is related to revenue. A study at one large
90% of respondents wanted their providers to use e-mail health maintenance
Author organization
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decrease in annual office visit rates among patients who Many providers have concerns about potential legal
had online access to their provider (Zhou et al, 2007). problems. E-mails are still provider–patient commu-
A decrease in office visits could mean decreased income nication and are discoverable—even deleted ones.
for the provider because office visits are billable visits. Only A poorly written e-mail may be used to portray you as
a few private insurance plans reimburse the provider for unprofessional. Before sending a message, be sure to
“e-visits” or “virtual visits” conducted by e-mail. Accord- double-check your e-mails for accuracy and appropriate
ing to the American Health Information Management language. Flippant or humorous messages may look
Association (AHIMA), the lack of reimbursement from disrespectful when viewed later, out of context.
Medicare is a limiting factor in the number of providers Other concerns about the use of e-mail have been
using e-mail. If the Medicare policy were to change, it identified. Providers may fear being bombarded by e-mails
is likely that e-mail communications between provider or having patients abuse the privilege. It may be difficult
and patient would increase. Medicare does reimburse to confirm the identity of the patient in an e-mail request.
for some live telemedicine services, not just electronic Messages can be delayed by hours or even days, and not
communications, and specific criteria must be met for receiving a response in a timely manner may have adverse
the visit to be reimbursable. Patients must be physically health consequences. Patients may e-mail about multiple
present at qualifying clinical sites, which must be in an complaints or problems. Viruses may be transmitted
area defined by the Centers for Medicare and Medicaid through attachments that may cause serious damage to
Services (CMS) as rural and underserved, a definition computer systems. Patients may come to expect a quick
that excludes as many as 80% of Medicare beneficiaries response to e-mail. Limiting e-mails to English only
( Joseph and Stuhan, 2015). More information about may cause problems for patients with limited English
the criteria for telemedicine visits is available at www proficiency. A certain level of patient literacy is required
.cms.gov/Outreach-and-Education/Medicare-Learn- for the e-mail exchange to be beneficial and efficient.
ing-Network-MLN/MLNProducts/Downloads/Tele-
health-Services-Text-Only.pdf. Currently, all but three Provisions for Using E-mail
state Medicaid programs pay for virtual visits, although If the decision is made to communicate with patients by
different states have different requirements for what e-mail, specific actions must be taken. Obtain written
types of services can be provided under virtual visits and permission from patients to communicate with them by
where. However, because Medicaid is administered in e-mail. Set expectations and limitations with patients
a state-by-state manner, no two programs are identical about what they can e-mail and how long it will take
in terms of coverage. to respond. Develop policies for the use of e-mail, in-
Confidentiality and protected health information (PHI) cluding how e-mail messages will be incorporated into
are other concerns with e-mail or electronic messaging. the patient’s medical record. Most EMR systems have a
State and federal laws vary when it comes to patient feature that will archive e-mails in the patient’s record.
privacy, particularly for patient conditions such as sexu- If this feature is not available, or if an EMR system is
ally transmitted diseases (STDs), HIV, substance abuse, not used, e-mails should be printed and saved in the
and treatment for mental health conditions. Laws about patient’s medical record. Provider–patient e-mails are
e-mailing patients who seek care for these conditions are considered health-care organization business records
very stringent and may cause confusion for providers. and, therefore, are subject to the same provisions for
The Health Insurance Portability and Accountability Act storage, retention, retrieval, privacy, and security and
(HIPAA) requires that electronic PHI, including e-mail, confidentiality as any other patient-identifiable health
be communicated in a secure way, that is, through an information. Confirm that you have the correct e-mail
encrypted system. There are many commercial services address for the intended recipient. Ensure that PHI
available that provide encrypted communication, but sent by e-mail is encrypted with access provided only
providers may be unwilling to pay for these services. In to authorized individuals who have an access code. Add
addition, patients may be unwilling to use encryption a confidentiality disclaimer to e-mail messages that
services to communicate with providers when their states the content is confidential and intended only for
unencrypted e-mail system is quick and simple to use. the stated recipient. The disclaimer also should state
Safeguarding the confidentiality of e-mail messages is that anyone receiving the e-mail in error must notify
difficult. Confidentiality can be breached by outsiders the sender and return or destroy the e-mail as per the
(hackers) or by patients and providers themselves who request of the sender. Never use e-mail distribution
reply to or forward e-mails to individuals outside the lists to send personal information.
patient–provider relationship. E-mails may be intercepted, For those providers who choose to utilize e-mail, you
altered, or delivered to the wrong address, resulting in can follow the American Medical Association’s Guidelines
people other than the intended recipients having access for Patient-Physician Electronic Mail (Policy H-478.997;
to the e-mail communication. 2012). The American College of Physicians (ACP)

and the Federation of State Medical Boards (FSMB) Patients often use the Internet and social media sites
Special Committee on Ethics and Professionalism to educate themselves about medical conditions and
developed a position paper that examines and provides treatment options. Information obtained from websites
recommendations about use of e-mail and other Web- may have tremendous influence on patients, whether or
based communication platforms. The consensus is that not that information is credible or supported by medical
e-mail is best used as an extension of the patient–provider research. A portion of the medical encounter may be
relationship and not a replacement for the relationship. spent discussing information that the patient brings
Finally, be sure you are familiar with and follow state to the visit, especially when you may have to educate
laws governing the use of e-mail communications. patients on the inaccuracy of information.
Sites devoted to specific diseases or conditions, from
Patient Portal asthma to Zollinger-Ellison syndrome, are plentiful.
A patient portal is a secure online Web-based platform Patients may access educational material, connect
that gives patients convenient 24-hour access to their with other people with the same condition, and find
own or a family member’s health information and providers who specialize in treating their condition. As
EMRs from anywhere with an Internet connection. a provider, you may find medical websites helpful to
Also, patient portals offer self-service options that can obtain clinical information about diseases, participate
eliminate “phone tag” with the health-care provider. The in continuing education programs, and collaborate
features of patient portals vary, but typically patients can with other providers across the country and around the
schedule appointments; request medication refills; and world. Although Web-based platforms continue to be
securely view and print portions of their medical record, used in these “traditional” ways, they are increasingly
including visit notes, discharge summaries, medications, used as a means of social networking.
immunizations, allergies, and most laboratory results. Social media sites, such as Facebook, Twitter, and
Other features may include downloading or completing Google Plus, have evolved from a preoccupation of high
intake forms, exchanging secure e-mail with members school and college students to the mainstream of social
of the health-care team, checking benefits and coverage, interaction that spans divisions of age, profession, and
updating contact information, and making payments. socioeconomic status. Several provider-only sites, such
Sometimes the patient portal can be used to send ap- as Sermo, Ozmosis, PA-CLife, and Nurse LinkUp,
pointment reminders to patients and to identify and offer providers the chance to connect with others in
provide patient-specific educational resources. Many their profession for knowledge sharing, networking,
hospitals offer patient portals similar to those used in and support. Access to these sites is controlled so that
ambulatory care settings. Some hospital systems also providers are able to share opinions and interact in a
offer a platform where patients (or their representative) safe, guarded environment. Providers may be required
can update friends and family about their health status. to disclose their name and credentials, preventing users
Patients also may use the portal to find a health-care from hiding behind a cloak of anonymity. Registered
provider or enroll in educational classes. 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.
Social Media Although these types of professional sites are growing
in number and popularity, many providers are also turning
Benefits of Social Media to social media for professional reasons or networking.
Social media refers broadly to Web-based tools that allow Hospitals and health-care systems use social media to
individuals to communicate quickly, easily, and broadly. communicate with colleagues and patients. A 2014 study
Many health-care organizations are using social media reported that more than 3,000 hospitals have accounts
to engage with patients and consumers. Health-care on at least one social media site, and approximately half
organizations also use social media to communicate their of all U.S. hospitals have an account on at least four
mission and vision, describe the services they offer, and sites. A number of hospitals have blogs authored by the
provide health education. Some organizations use social chief executive officer in an effort to personalize their
media to promote wellness and sponsor online support message. Proponents of social networking cite benefits,
forums where individuals who are dealing with chronic such as an increased presence in the community, the
health issues or catastrophic conditions can find support ability to promote certain services, and marketing to
from others who are having similar experiences. On attract new patients. Others indicate that the use of social
some sites, physicians and other clinicians educate the networking offers a way to stay abreast of medical news,
public on common diseases, what can be done to cope share practice management tips, and build consensus
with conditions, and how to maximize the quality of on issues important to them. The ease of facilitating
life for the individual who is suffering from the disease. communication is also an advantage, particularly when

communicating findings from research. New findings Provisions for Using Social Media
can be disseminated through social media the minute Social media is likely here to stay. Health-care pro-
they are learned, putting useful information in the fessionals need to carefully consider whether to have
hands of clinicians more quickly than the traditional a presence on social media. If the decision is made to
dissemination through professional journals or meet- do so, it is recommended that separate sites be used
ings. Often clinical research is sponsored by industry, for professional and personal purposes to maintain ap-
and few people may evaluate the content before it is propriate boundaries. A position paper from the ACP
published in a journal. In an online community, review and FSMB published in 2016 examines and provides
by potentially thousands of professionals may promote recommendations about the influence of social media
superior credibility. on the patient–provider relationship, the role of these
media in public perception of physician behaviors, and
Concerns About Social Media strategies for provider–patient communication that pre-
Despite the benefits of social media, there are also con- serve confidentiality while best using these technologies.
cerns and challenges. Perhaps the greatest concern—and On any site to which patients have access, a disclaimer
the reason to include the topic of social media in a text should be used to state clearly that the provider is not
on documentation—is the permanence of information giving medical advice to individuals. Guidelines for
posted on sites. Of equal concern is that there is no postings should be established, as should guidelines for
anonymity on the Web. Information posted on most dealing with “friend” requests. The FSMB specifically
social media sites is indexed on Google and can be found discourages physicians from interacting with current
by patients, supervisors, potential employers, attorneys, or past patients on personal social networking sites.
and others. Even when information is removed from a Students in professional programs and licensed pro-
site, it is usually archived somewhere and accessible in viders should take extra precautions to ensure that they
the future. Lawsuits have been filed against physicians are not in violation of policies of the school, employer,
and other health-care providers for posting photographs or professional liability carrier or the ethics codes of a
of patients without their consent. Before posting in- hospital or professional society. Remember that social
formation on a social site, health-care providers should media sites are not HIPAA-compliant and should
consider how the content would likely be interpreted never be used for any patient–provider communication.
in various settings, such as an interview, a departmental By applying these commonsense principles, provid-
meeting, or during litigation. The information, whether ers should be able to realize the benefits and protect
in written form or photographs, should be considered themselves from the perils of social networking.
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 Summary
“what happens in Vegas stays in Vegas.” Health-care
providers who have a presence on social media should In addition to SOAP notes, you may use other forms
operate on the premise that “what happens in Vegas of documentation, such as problem lists, medication
shows up on the Internet the rest of your life.” lists, and flow sheets, to document a patient’s medical
Another concern related to social media is the potential information. Correspondence between medical providers
to breach patient confidentiality. Even with the best of should be incorporated into the patient’s medical record.
intentions, it is easy to divulge PHI when posting a case Demographic and billing information may be kept in
and seeking input from colleagues. Any information the patient record, often in a section that is separate
that is shared should be generic enough that no one from medical information. If you or your institution
can identify a patient in the course of reading a post. decides to allow e-mail between patients and providers,
Another challenge is the blurring of the boundaries of all e-mails should be made a permanent part of the
the patient–provider relationship and the merging of patient record. EMRs and Web-based patient portal
professional and personal lives. Providers must decide platforms will have a system design that promotes security
whether they will accept a request from patients to of protected health information and that captures who
engage in a social media relationship. Although many accesses the patient’s record. Health-care providers and
websites allow users to choose privacy settings and to institutions should develop and prominently display
control which personal content is available to whom, procedures and guidelines for use of e-mail or patient
once information is posted on social media, there is portals, and they must have policies that deal with se-
no longer any control over that information. Providers curity breaches. To reinforce the content of this chapter,
also should realize that information could be posted on please complete the worksheets that follow. And be sure
other sites and could be viewed as providing medical to review Appendix A, the Document Library, for full
advice, resulting in a liability risk. case examples of patient documentation.

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.


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.


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?

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.

Worksheet 8.3
Name:
Abbreviations
of this chapter.
ACP ACE
AHIMA CMS
CPT ECG
EMR FSMB
HIPAA HMO
HPI ICD
INR OTC
PHI PMH
PT SSN
STD

Chapter 9
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.
Administration (FDA) has instituted a program to

Introduction better distinguish between them. Additionally, the
FDA approves one or two new drugs each week and
According to the National Ambulatory Medical Care
makes a dozen or so changes in indications for cur-
Survey, 922.6 million visits were made to office-based
rent medications already approved. Physicians, nurse
health-care providers during 2013. In more than two
practitioners, and physician assistants cannot possibly
thirds of these visits, there was “mention of medications,”
keep up with all the relevant information available on
which is defined as medications provided, prescribed,
all the medications they might prescribe. When you
or continued. At 40% of all visits, two or more drugs
factor in handwritten prescriptions and the number of
were recorded. According to the QuintilesIMS Health
steps between writing a prescription and dispensing a
Report, more than 4.45 billion prescriptions were
medication, it is easy to see how errors can occur.
dispensed by retail pharmacies in the United States
In 2010, Kaushal and colleagues published a study
in 2016. It has been estimated that another 1 billion
that evaluated prescription errors in community-based
prescriptions are written each year that are never filled.
office settings. They found that prescribing errors were
The medication use process is particularly susceptible
higher than what had been previously reported with
to errors because of a number of reasons:
a range of 37.3 to 42.5 per 100 paper-based prescrip-
• The large number of drugs available tions containing errors. The most commonly identified
• A lack of precisely defined best practices errors were inappropriate abbreviations, duration errors
• Confusion between drug names, dosage forms, (how long to take the medication), and direction errors
routes of administration, doses, and units of dose (instructions for how patients should use the medication).
measurement There were 87.6 illegibility errors per 100 prescriptions,
the most frequent type of which were illegible signature
The number of look-alike and sound-alike drug names and strength or strength units. The study participants
is a matter of such concern that the Food and Drug were divided into two groups: those who continued
195

to handwrite prescriptions and those who adopted registered, or otherwise permitted, by the United States
electronic prescribing (or e-prescribing). At the end or the jurisdiction in which the practitioner practices
of the study, there was no significant rate of change or performs research, to distribute, dispense, conduct
statistically among errors in paper-based prescriptions. research with respect to, administer, or use in teaching
In the e-prescribing group, error rates decreased nearly or chemical analysis a controlled substance in the course
sevenfold from 42.5 per 100 prescriptions to 6.6 per of professional practice or research.”
100 prescriptions. Illegibility errors were completely Every person or entity that handles controlled sub-
eliminated. E-prescribing is discussed in detail later in stances must be registered with the DEA or be exempt
this chapter. However, before looking at e-prescribing, it by regulation from registration. The DEA registration
is necessary to understand the basic concepts related to grants practitioners federal authority to handle controlled
prescribing, such as the role of the Drug Enforcement substances. The registration is used to track practitioners’
Agency (DEA), state and federal laws that govern pre- prescribing practices related to controlled substances and
scribing authority, and controlled versus noncontrolled to control the unauthorized prescribing of controlled
substances. Likewise, a prescriber must understand the substances. Each qualified practitioner is assigned a unique
elements that are required in a prescription regardless DEA identifier number. A prescription for a controlled
of the means by which the prescription is generated. 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-
Federal and State Regulations sponsibilities under the CSA and to provide guidance
in complying with federal regulations. The manual may
and Prescribing Authority be found at the DEA’s website at www.DEAdiversion.
usdoj.gov. Any DEA-registered practitioner may engage
The DEA was established in 1973 to serve as the pri- in only those activities that are authorized under state
mary federal agency responsible for the enforcement of law for the jurisdiction in which the practice is located.
the Controlled Substances Act (CSA). The CSA sets When federal law or regulations differ from state law
forth the federal law regarding both illicit and lawful or regulations, the practitioner is required to abide by
(pharmaceutical) controlled substances. With respect to the more stringent aspects of both the federal and state
pharmaceutical controlled substances, the DEA’s statutory requirements. In many cases, state law is more stringent
responsibility is twofold: to prevent diversion and abuse of than federal law and must be complied with in addi-
these drugs while ensuring that an adequate and uninter- tion to federal law. If a state requires a separate license
rupted supply is available to meet the country’s legitimate for controlled substances, then it should be obtained
medical, scientific, and research needs. In carrying out this first and should be included in the federal application.
mission, the DEA works in close cooperation with state Practitioners should be certain that they understand the
and local authorities and other federal agencies. regulations from their state as well as the DEA related
Under the framework of the CSA, the DEA is to controlled substances. DEA regulations prohibit a
responsible for ensuring that all transactions related physician from delegating the use of his or her signature
to controlled substances take place within the “closed and DEA registration to another person. Therefore, if
system” of distribution established by Congress. Under a nonphysician provider is delegated the authority to
this closed system, all legitimate handlers of controlled prescribe controlled substances, then the provider also
substances—manufacturers, distributors, practitioners, must be registered with the DEA. Prescribing authority
pharmacies, and researchers—must be registered for both physician assistants and nurse practitioners by
with the DEA and maintain strict accounting for all state may be viewed at www.deadiversion.usdoj.gov/
distributions. Under the CSA, the term practitioner is drugreg/practioners/mlp_by_state.pdf.
defined as “a physician, dentist, veterinarian, scientific Use the practitioner’s manual from the DEA to
investigator, pharmacy, hospital, or other person licensed, answer the questions in Application Exercise 9.1.

Chapter 9 Prescription Writing and Electronic Prescribing | 197

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.

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
Since October 1, 2008, all written prescriptions for

outpatient drugs prescribed to a Medicaid beneficiary
Safeguards for Prescribers
were required to be on tamper-resistant prescriptions In enforcing the CSA, it is the DEA’s responsibility to
containing specific characteristics as outlined by the ensure that drugs are not diverted for illicit purposes.
Centers for Medicare and Medicaid Services (CMS). Unfortunately, the United States is now experiencing an
The law applies only to written prescriptions for covered alarming problem with prescription drug abuse. More
outpatient drugs; prescriptions that are transmitted than 6 million Americans are abusing prescription
from the prescriber to the pharmacy verbally, by fax, drugs—that is more than the number of Americans
or through an e-prescription are not impacted by the abusing cocaine, heroin, hallucinogens, and inhalants
statute, and so those methods may be used as alterna- combined. Researchers from the Centers for Disease
tives to a written prescription. The tamper-resistant Control and Prevention (CDC) reported more than
characteristics are as follows: 52,000 opioid-related deaths in 2015—more deaths
• One or more industry-recognized features than cocaine and heroin combined. All prescribers
designed to prevent unauthorized copying of a have an obligation to protect their DEA number and
completed or blank prescription form minimize the risk of prescription forgery and tampering.
• One or more industry-recognized features In addition to the federally required security controls,
designed to prevent the erasure or modification practitioners can use additional measures to ensure
of information written on the prescription by the security of paper-based prescriptions:
prescriber • Keep all prescription blanks in a safe place where
• One or more industry-recognized features they cannot be stolen; minimize the number of
designed to prevent the use of counterfeit prescription pads in use.
p rescription forms • Write out the actual amount prescribed in addi-
Rather than having to take the time to identify Medicaid tion to the numerical value to discourage alter-
patients, most prescribers use the same prescription blanks ations of the prescription.
for all patients. Additionally, most states have their own • Use prescription blanks only for writing a
requirements for tamper-resistant prescriptions. More prescription and not for notes or orders such as
information about state requirements can be found laboratory or other diagnostic tests.
at www.cdc.gov/phlp/docs/menu-prescriptionform. • Never sign prescription blanks in advance.
pdf. An example of a tamper-resistant prescription is • Assist the pharmacists when queries are made to
shown in Figure 9-1. verify information about a prescription order; a

Figure 9-1 Tamper-resistant prescription pad.

OK Correx
F09_01 6662_C_F09_01.eps Date
Initials
Artist Date
04/05/18
CopyrightAB/CO
© 2019 by F. A. Davis
Check ifCompany.
revision X All rights
Editor's reviewreserved.
2nd color OK Correx
B/W X 4/C 2/C PMS

corresponding responsibility rests with the phar- Table 9-1 Drug Enforcement Agency
macist who dispenses the prescription to ensure Classification of Controlled
the accuracy of the prescription. Substances*
• Contact the nearest DEA field office to obtain or
furnish information regarding suspicious prescrip- Schedule Comments
tion activities. I High potential for abuse. No accepted
• Do not include your DEA number on preprinted medical use.
prescription blanks. Instead, leave a blank line II High potential for abuse. Use may lead
to severe physical or psychological
and write in the number only when required for a dependence.
controlled substance. III Some potential for abuse. Use may lead
• Keep an inventory of the number of prescrip- to low to moderate physical dependence
tion pads you have on hand, making it easier to or psychological dependence.
identify whether pads are missing. IV Low potential for abuse. Use may lead
• Do not use your DEA number as an identifier if to limited physical or psychological
there is another option (such as a National P rovider dependence.
Identifier [NPI] number). Using your DEA num- V Subject to state and local regulations.
Abuse potential is low.
ber for identification increases the risk of misuse
and the possibility of forged prescriptions. *As in the Controlled Substances Act of 1970. Drugs are categorized
according to their potential for abuse: the greater the potential, the more
• Do not display your DEA certificate. File it in a severe the limitations on their prescription.
locked cabinet.
• Limit the number of people who have access to
your DEA number. Instruct office staff to refer all • Patient identification
requests for your DEA number directly to you. • The inscription
• The subscription
• Signa
Controlled and Noncontrolled • Indication
• Refill information
Substances • Generic substitution
• Warnings
The drugs and other substances that are considered • Container information
controlled substances under the CSA are divided into • Prescriber’s signature
five schedules. A complete list of the schedules is up- A summary of these elements is shown in Table 9-2.
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 Writing Prescriptions for
a currently accepted medical use in treatment in the
United States and on their relative potential for abuse
Noncontrolled Medications
and likelihood of causing dependence when abused. Prescriber Identification
All drugs listed in Schedule I have no currently accepted In many cases, this is preprinted on a standard prescription
medical use and, therefore, may not be p rescribed, admin- form. This includes the name and title of the prescriber
istered, or dispensed for medical use. In contrast, drugs and the address and telephone number of the practice
listed in Schedules II through V all have some accepted or institution. When the prescriber is a nonphysician,
medical use and, therefore, may be prescribed, adminis- some states require that the supervising physician’s name
tered, or dispensed. Table 9-1 presents the categories of be printed on the prescription form as well.
controlled substances as defined by the CSA.
Patient Identification
This includes the patient’s name, address, age or date of
Elements of a Prescription birth, and, sometimes, weight. It is recommended and,
in some states it is required, that you use the patient’s
Certain elements should be included in every prescrip- legal name instead of a nickname. If you are unsure of
tion, whether it is for a noncontrolled or a controlled the patient’s legal name, ask to see a driver’s license or
substance. The basic elements include the following: an insurance card if available. This helps avoid confusion
• Date the prescription was written and correctly identifies the patient. The date of birth
• Prescriber identification is more commonly requested than the patient’s age

Table 9-2 Summary of Elements of a 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
because it allows more specific identification. When a on how the quantity should be written and refill
prescription is written for a pediatric patient, you should information, so it is recommended that you ask the
include the patient’s weight so that the pharmacist can patient whether he or she uses a mail-order service
verify that the medication has been dosed appropriately. before writing the prescription.
Inscription Signa or sig
This includes the name and strength of the medication. This provides instructions to the patient on how to take
Generic or trade names may be used. Avoid abbreviating the medication and should be as specific as possible. It
names of medications to help reduce the possibility of should include the route; any special instructions, such
error. There are exceptions for well-known medications; as to take on an empty stomach or take with food; and how
for instance, trimethoprim-sulfamethoxazole is commonly often to take. When the medication is prescribed on a
abbreviated TMP/SMX. The strength is the amount per prn basis, the reason for taking the medication should be
dosing unit, such as a 50 mg tablet or 250 mg per 5 mL. included. Avoid writing vague or ambiguous instructions,
Some medications come in many different strengths and such as take as directed or apply in usual manner. Numerous
forms (i.e., tablets and liquids). If you are unsure which studies have documented that patients usually do not
strengths and forms are available, you should consult a pre- remember all the information they are given during the
scribing guide, pharmacology text, or medication reference course of a provider–patient encounter; therefore, it is
book. The strength is not the same as the total amount to necessary to provide instructions that are as detailed
be taken by the patient over the course of the prescription. and accurate as possible to reduce the chance that the
medication may be taken inappropriately.
Subscription
This provides information to the pharmacist on dos- Indication
age form and number of units or doses to dispense. Including the indication for the prescription is mandatory
Instructions about the dosage form may be tablets, in some states. Even when states do not require an indica-
capsules, or suspension, for example. If a liquid or tion, the Institute for Safe Medication Practices (ISMP)
semiliquid is to be dispensed, provide the quantity, recommends including it for two reasons. First, many drugs
such as how many milliliters of suspension or how have names that look and sound alike but are taken for
many grams in a tube. The amount dispensed should very different reasons. Second, illegible writing may cause
be the amount needed to complete a course of treat- confusion or misinterpretation. Including the indication
ment. For example, if a patient is to take a tablet for the prescribed medication provides another safety
twice a day for 10 days, the subscription, or amount check for the prescriber, the pharmacist, and the patient.
to dispense, would be 20 tablets. You will often see
“#20” or “Disp: 20 tabs”; either is acceptable. Many Refill Information
patients use a mail-order pharmacy service provided This should be included on the prescription form and
by their health insurance plan administrator. Such can be written as the number of times a prescription
mail-order pharmacies may have specific requirements may be refilled or a period during which the prescription

may be refilled. Most states impose a 1-year maximal The National Coordinating Council for Medication
refill period. Patients taking medications for chronic Error Reporting and Prevention has identified several
conditions should be assessed at least annually, so it abbreviations that are particularly dangerous because they
is not prudent to write medication refills for more have been misunderstood consistently. These abbrevia-
than a 1-year period. If the patient has prescription tions are shown in Table 9-4. The council recommends
coverage as a benefit of an insurance plan, it is a that these should never be used in prescription writing.
good idea to consult the formulary for that insurance Refer to Appendix C for the ISMP list of Error-Prone
company to see whether the medication you want to Abbreviations, Symbols, and Dose Designations that
prescribe is covered and whether there are regulations should be avoided when writing prescriptions.
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 Writing Prescriptions for
to the patient if he or she is prescribed a medication
that is covered by the insurance plan, but that is not Controlled Medications
the only factor to consider when deciding which
medication to prescribe. Two main differences between noncontrolled and
controlled medications are the quantity initially dis-
Generic Substitution pensed and the refills. State laws regulate the quantity
Most prescription forms will allow you to indicate of controlled medications that can be prescribed during
whether the medication should be dispensed as written a certain period. When indicating the quantity, write
(DAW) or whether substitution of a generic form of the out the number instead of writing it numerically (“ten”
medication is permitted. Generic medications usually instead of “10”), or do both. An example is shown in
offer considerable cost savings to the patient, and, with Figure 9-3. This helps prevent modification of the
few exceptions, it is preferable to allow substitution. prescription. State laws also regulate the number of
refills, if any, allowed for controlled substances. It is your
Warnings responsibility as a prescriber to know these regulations.
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 MEDICOLEGAL ALERT !
pharmacist filling the prescription will affix the appro-
priate warnings listed in the prescribing information According to some studies, up to 25% of ambulatory
automatically, but you should include this information patients experience adverse medication events. Up to
on the form. This provides another safety check between 6% of these adverse events could have been reduced or
the prescriber and the pharmacist. prevented altogether. Many preventable events involve
Container Information prescribing a medication to which the patient has a
known allergy. Before writing any new prescription for
In many states, the law requires that pharmacists a patient, always ask about allergies to any medications,
dispense medications in childproof containers. If and prescribe accordingly. Sometimes, when asked about
the patient taking the medication is likely to have medication allergies, patients may describe what sounds
difficulty opening such a container (such as a patient like side effects of a medication rather than describing a
with arthritic hands), indicate that a non-childproof true allergic reaction. If you have any doubt whether a
container should be used. patient is truly allergic to a medication, discuss the risk
Signature and benefits of taking the medication with the patient,
and document that discussion. If the decision is made to
Your signature authenticates the prescription. On a
prescribe the medication, be sure that the patient knows
prescription form, your signature should include your
what signs or symptoms to be aware of and what action
name and title. Signatures can be unique and may
to take should any develop. You should always consider
identify people, much like fingerprints, but above all
what medications the patient is already taking and
they should be legible. Figure 9-2 shows a completed
determine the likelihood of drug interactions. Some-
prescription with all the elements labeled.
times, the benefit of prescribing a specific medication
Although frequently used when writing the i nstructions,
may outweigh the possible risk for a drug interaction
there is controversy about whether abbreviations should
or side effect; document in such a way that reflects that
be used at all. A list of commonly used abbreviations is
you are aware of possible side effects or drug inter-
shown in Table 9-3. Some providers and pharmacists
actions but that you believe the medication to be the
think that writing out instructions, rather than using
most appropriate treatment for the patient’s condition.
abbreviations, reduces the chance of a medication error.

Primary Care and Pediatric Associates

2400 Main St. Glendale, AZ 85308
1 Phone: 623-572-3000 Fax: 623-572-3400
David M. Wright, DO Debbie D. Sullivan, PA-C
DEA # ____________________________________________ DEA # ________________________________________
-DQH6PLWK
Name: ______________________________________________________________
Age: ___________________________
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Address: _____________________________________________________________ ;;;;;;;;
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_____________________________________________
8 + 11
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1. Prescriber’s Information 6. Indication

2. Patient’s Information 7. Refill information
3. Inscription 8. Generic substitution
4. Subscription 9. Warnings (not applicable for this medication)
5. Signa or Sig 10. Container information
11. Signature
Figure 9-2 Prescription form showing elements.
Common Errors in Several studies have identified errors commonly made

in the process. These studies have shown that as many
Prescription Writing as one third of all outpatient prescriptions contain
errors. Specific errors fall into these general categories:
According to the 2014 National Ambulatory Medical • Illegibility of any part of the prescription
Survey, almost 77% of provider–patient encounters for • Omissions: leaving off the drug name, strength,
acute problems result in the writing of one or more or quantity to dispense; minor omissions include
prescriptions. Serious errors can occur, both in writing not putting the patient’s name, date, directions for
the prescription and in dispensing the medication. Author
use, or prescriber’s
Sullivan
ISBN #
name 6662
Author's review
(if needed)
OK Correx
F09_02 6662_C_F09_02.eps Date
Initials
Artist DateCompany. All rights reserved.
03/06/18
AB Editor's review
Check if revision
2nd color OK Correx
B/W 4/C 2/C X PMS
42p x 41p0 Initials

Table 9-3 Common Abbreviations Used

in Prescription Writing
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 os left eye
sinister
per os PO by mouth
post cibum pc after meals
pro re nata prn as needed
quaque 3 q3h every 3 hours
hora
quaque die qd every day
• 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 It does not contain quantity information. Prescriptions
state regulation, not spelling out the quantity of should be written using the patient’s legal name, so
a controlled substance, including refills when not the prescriber would need to determine if the legal
allowed by law name is Billy.
Author ISBN #
• Unclear quantity prescribed: quantity does not Sullivan 6662
Author'
(if ne
match the directions, specifying non–trade-size Fig. # Document name
topical or liquid preparations

Electronic Prescribing
UF09_01 6662_C_UF09_01.eps
Ini
• Incomplete directions: not identifying the route,
Artist Date
03/06/18
AB Editor's
quantity to be taken at each dose, frequency of Check if revision
In Chapter 1, we discussed several factors influencing the 2/C 2nd color
dosing B/W X 4/C PMS
implementation of an electronic medical record (EMR)
• Leading and trailing zeros: not putting a leading Final Size (Width X Depth in Picas)
system as a means of delivering safe, high-quality,
23p3 x 10p7effi- Ini
zero before a decimal expression of less than 1,
cient, and cost-effective health care. Similarly, electronic
including a trailing zero after a decimal
prescribing, or “e-prescribing,” has been targeted as a key
Seeing the actual written prescription is helpful to factor in preventing medical errors and reducing adverse
identify errors, as illustrated in Example 9.1. drug events (ADEs). E-prescribing has been defined as
the computer-based electronic generation, transmission,
EXAMPLE 9.1 and filling of a prescription, taking theAuthor
place of paper andISBN # Author's review
faxed prescriptions. A more formal definition
Sullivan is provided6662 (if needed)
Look at the two prescriptions shown and identify er-
in the Medicare Part D prescriptionUF09_02drug program:
rors in each. Notice the tamper-resistant feature that 6662_C_UF09_02.eps
Initials
appears as “VOID” across the paper. E-prescribing means the transmission, using electronicDate 03/06/18
Artist
AB
The prescription for Augmentin does not include the media, of prescription or prescription-related informa-Check if revision Editor's review
2nd color
subscription (dosage form), and there is a mismatch tion between a prescriber, dispenser,Bpharmacy
/W X 4/Cbenefit2/C PMS
between number to dispense (14) and frequency and manager, or health plan, either directly or through an
Final Size (Width X Depth in Picas)
Initials
23p2 x 10p8
number of days to take (twice a day for 10 days = 20). intermediary, including an e-prescribing network.
The prescription for Lantus is meant to be 8 (eight) E-prescribing includes, but is not limited to, two-way
units but could easily be mistaken for 80 (eighty) units. transmissions between the point of care and the dispenser.

Table 9-4 Dangerous Abbreviations to Avoid

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 The period after the Q has sometimes been mistaken for an I, and
every day the drug has been given qid (four times daily) rather than daily
Q.O.D. Latin abbreviation for Misinterpreted as Q.D. (daily) or Q.I.D. (four times daily); if the O is
every other day 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 Misinterpreted as the Latin abbreviation OU (both eyes), OS (left eye),
ears, left ear, right ear 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
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 2. Eligibility and benefits queries and responses be-
Prescribing tween prescribers and Part D sponsors
3. Eligibility queries between dispensers and Part
Since early 2000, many federal and state organi-
D sponsors
zations have called for the adoption of a national
electronic-prescribing system. Several key federal MMA also required CMS to implement pilot projects
regulations include provisions or mandates related to to test additional standards related to formulary and
e-prescribing. Passage of the Medicare Modernization benefit information, prior authorization, medication
Act of 2003 (MMA) resulted in a significant increase in history, and fill status notification. These are all import-
attention and focus on e-prescribing. One component ant components of an electronic prescribing system,
of the MMA was Medicare Part D, which introduced especially one that could be implemented nationally.
an entitlement benefit for prescription drug coverage In 2007, electronic prescribing became legal in all
for Medicare beneficiaries. Under the Part D program, 50 states. Congress passed the Medicare Improvements
the MMA mandates that plans accept electronic for Patients and Providers Act in 2008. The act pro-
prescriptions; it authorizes the Department of Health vided for a 2% annual bonus for providers who started
and Human Services to mandate transactive standards; e-prescribing and penalties for those who did not. The
and it provides economic incentives to prescribers for incentive program ended in 2013.
the adoption of e-prescribing. A report released by the
Institute of Medicine in July 2006, Preventing Medication Qualified Electronic Prescribing
Errors, received widespread publicity and helped build Similar to the “meaningful use” standard imposed on
awareness of e-prescribing’s role in enhancing patient EMR adopters, criteria have also been developed for
safety. In the same year, CMS enacted three foundation “qualified e-prescribing.” To qualify, a system must be
standards that apply to all electronic prescribing done capable of all of the following:
under Part D of the MMA. The foundation standards
• Generating a complete active medication list in-
cover three broad areas:
corporating electronic data received from applica-
1. Transactions between prescribers and dispensers ble pharmacy drug plans if available
for new prescriptions, refill requests, prescription • Selecting medications, printing prescriptions,
changes and/or cancellations, and related mes- electronically transmitting prescriptions, and con-
saging and administrative transactions ducting all safety checks

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 # ____________________________________________ 06

DEA # ___________________________________________
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Name: ________________________________________________________________
Age: ____________________________
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Address: ______________________________________________________________ ;;;;
Date: ____________________________
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Refill ______ times Childproof Container: [ yes no
__________________________________________________ 'HEELH6XOOLYDQ3$&
_________________________________________________
Dispense as written Substitution permitted
Figure 9-3 Controlled substance quantities.

• Providing information related to the availability prescribers and their office staff,
Sullivan 6662 pharmacists, payers,OKandCorrex
(if needed)
of lower-cost, therapeutically appropriate alterna- employers.Fig. E-prescribing

# Documentprovides
name point-of-care access
F09_03
tives (if any) to patientArtist
eligibility and formulary
6662_C_F09_03.eps
Date
coverage,Initials
which helps
Date
• Providing information on formulary or tiered for- prescribersABdetermine the most clinically

03/06/18 appropriate
Editor's review
mulary medications, patient eligibility, and autho- and cost-effective medication for patients. It allowsOKforCorrex
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requirements, such
the patient’s drug plan as prior authorization,
41p0 x 36p8 quantity restrictions, noncovered
Initials
Date
drugs, and drug tiers. It provides a real-time view of a

Benefits of E-Prescribing patient’s medication history to all providers; because all
Many of the perceived benefits of e-prescribing are re- providers see the same information, it alerts prescribers
lated to decreasing medication errors and the incidence to potential drug–allergy and drug–drug interactions
of ADEs. It is important to understand not only how and decreases the chance of different prescribers giving
e-prescribing affects patient safety but also how it affects the same medication. Access to a Clinical Decision

Support System (CDSS) helps prescribers make informed mandate it. They also permit pharmacies to receive,
decisions about which medication is most effective. dispense, and archive these electronic prescriptions.
E-prescribing brings automation of the entire pre- Practitioners who wish to prescribe controlled sub-
scribing process. New prescriptions go directly to the stances electronically must obtain a third-party audit or
pharmacy’s computer, and renewal requests come back certification to certify that each electronic prescription
to the prescriber’s e-prescribing and EMR application and pharmacy application to be used to sign, transmit,
for authorization. This creates a closed system that or process prescriptions for controlled substances com-
prevents prescription tampering and fraud. It also elim- plies with DEA regulations pertaining to electronic
inates handwritten prescriptions and errors related to prescriptions for controlled substances. E-prescribing
illegibility and transcribing and data entry. It decreases software must be upgraded to meet standards set
the amount of time spent on telephone calls from dis- by the FDA. Providers must go through an identity
pensers to prescribers for queries related to illegibility, proofing process involving two-factor authentication
noncovered drugs, and prior authorization requirements. (TFA) credentials. DEA allows the use of two of the
This allows prescribers to spend more time providing following: something you know (a knowledge factor),
patient care and results in cost savings to pharmacies something you have (a hard token stored separately
and payers. E-prescribing may also increase patient from the computer being accessed), and something
compliance because of cost-effectiveness, convenience, you are (biometric information, such as a fingerprint
and a decrease in the total time it takes from generation screen). As of early 2017, only around 4% of prescribers
of a prescription to dispensing of a medication. nationwide were engaged in EPCS. More information
on the ruling may be obtained at the DEA website:
Barriers to E-Prescribing www.deadiversion.usdoj.gov/ecomm/e_rx/index.html.
Many of the potential barriers associated with electronic The Office of the National Certification for Health
prescribing are the same as those for using an EMR Information Technology released a report in July 2014
system. Cost can be an issue to both prescribers and that looked at e-prescribing trends in the United States
pharmacies. The pharmacy’s software vendor charges between 2008 and 2014. In 2008, only 7% of physicians
transaction fees, and there may be a one-time start-up fee were e-prescribing using an EMR; this increased to
and monthly charges. A free stand-alone e-prescribing 70% by 2014. From December 2008 to April 2014,
system is available through the National ePrescribing community pharmacies enabled to accept e-prescriptions
Patient Safety Initiative, so prescribers may not have increased from 76% to 96%. In 2008, only 4% of new
to purchase a system; however, they may be charged and renewal prescriptions were sent electronically. By
monthly access fees for certain services. Several barri- 2013, 57% were sent electronically.
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 Summary
standard for the signa, or the instructions to patients
on how to take the medication. Some systems allow for Prescribing medications is one of the most common
free-text, whereas others use a drop-down menu, which tasks that you will perform as a health-care provider.
may actually increase errors in this part of the prescrip- You have the responsibility to understand and follow
tion. Like EMR systems, e-prescribing systems have federal and state laws that grant and govern prescribing
to meet certification criteria. Other barriers identified authority. Avoid the use of dangerous abbreviations
include software functionality problems, input errors by and pay special attention to commonly confused
prescribers, inaccuracies in formulary information, and drugs. Because of the growing epidemic of medication
system incompatibilities that exist between prescriber misuse and overdose, ensure that you are taking steps
software and pharmacy dispensing software. to prevent altering of prescriptions, especially of con-
One barrier was the inability to prescribe controlled trolled substances, and to safeguard prescription pads
substances electronically; however, the DEA revised a from unintended access. The adoption of electronic
regulation that gave prescribers the option of writing prescribing has demonstrated effectiveness in reducing
prescriptions for controlled substances electronically. common prescription errors and eliminating illegibility
The Electronic Prescriptions for Controlled Substances errors. To reinforce the content of this chapter, please
(EPCS) rule became effective on June 1, 2010. These complete the worksheets that follow. And be sure to
regulations provide the option of transmitting prescrip- review Appendix A, the Document Library, for full
tions for controlled substances electronically but do not case examples of patient documentation.

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.

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.

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.

Worksheet 9.3
Name:
Medication Review II
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.

Worksheet 9.4
Name:
Medication Review III

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.

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 CDC
CDSS CMS
CSA DAW
DEA EMR
EPCS FDA
ISMP MMA
NPI TFA
TMP/SMX

PART III Documentation Related to Inpatient Care
Chapter 10
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.
be legible and complete, and must be authenticated and

Introduction dated promptly by the person (identified by name and
discipline) who is responsible for ordering, providing, or
According to the 2017 American Hospital Association
evaluating the service furnished. (i) The author of each
Annual Survey, there were about 35.1 million hospital
entry must be identified and must authenticate his or her
admissions in the United States in 2015. The average
entry. (ii) Authentication may include signatures, written
length of stay for hospitalized patients was 4.8 days.
initials or computer entry. (2) All records must document
Using a conservative estimate of 25 orders per patient,
the following, as appropriate: (i) Evidence of a physical
this amounts to 877.5 million orders generated annually.
examination, including a health history, performed no more
This estimate gives an indication of the enormity of the
than seven days prior to admission or within 48 hours
work associated with managing hospitalized patients
after admission. (ii) Admitting diagnosis. (iii) Results of
and may help you appreciate the need for accuracy and
all consultative evaluations of the patient and appropriate
attention to detail when authoring documents that
findings by clinical and other staff involved in the care
relate to patient care.
of the patient. (iv) Documentation of complications,
Regulatory agencies such as The Joint Commission
hospital acquired infections, and unfavorable reactions
and the Centers for Medicare and Medicaid Services
to drugs and a nesthesia. (v) Properly executed informed
(CMS) have standards for the content of medical
consent forms for procedures and treatments specified by
records for hospitalized patients. Although it is rather
the medical staff, or by Federal or State law if applicable,
lengthy, CMS Section 482.24 of Title 42 from the
to require written patient consent. (vi) All practitioners’
Code of Federal Regulations (2004) deserves inclusion
orders, nursing notes, reports of treatment, medication
because it serves as the basis for much of the content
reports, radiology and laboratory reports, and vital signs
of this chapter:
and other information necessary to monitor the patient’s
(c) The medical record must contain information to condition. (vii) Discharge summary with outcome of
justify admission and continued hospitalization, support hospitalization, disposition of case, and provisions for
the diagnosis, and describe the patient’s progress and follow-up care. (viii) Final diagnosis with completion
response to medications and services. (1) All entries must of medical records within 30 days following discharge.
217

Admission History at the hospital, whether there is an actual admission,

outpatient testing, or visit to an emergency department.
and Physical Examination Policies on how to identify patients will vary from hospital
to hospital; it is your responsibility to know the policy
One of the most important documents generated for each institution in which you have privileges.
during a patient’s hospital stay is the admission history
and physical examination (H&P). Although CMS Chief Complaint (CC) and History
has regulations pertaining to when the H&P must of Present Illness (HPI)
be done, some hospitals may have different and often The chief complaint (CC) should reflect the primary
more stringent requirements; you are responsible for reason for the hospitalization and is best recorded in
knowing and following your facility’s by-laws. Numerous the patient’s own words. The same CMS Documen-
members of the health-care team use information from tation Guidelines for Evaluation and Management
the H&P as the cornerstone of their interactions with (E/M) of Services discussed in Chapter 2 pertain to the
and management of the hospitalized patient. There are admission H&P; therefore, you should document the
some differences between medical and surgical admis- same elements of the history of present illness (HPI).
sions. A medical admission indicates that the patient The HPI should tell the story of the patient and the
has a condition that will be managed primarily with symptoms that prompted the patient to come to the
medical therapies; pneumonia, deep vein thrombosis, hospital. It is generally the longest and most detailed
sepsis, or altered mental status are examples of condi- part of the H&P.
tions that are managed medically. At times, the patient
will present with a medical complaint that will require Past Medical History (PMH)
urgent or emergent and unplanned surgical interven- You will see records where the HPI contains past medical
tion. For example, a patient who presents with acute history (PMH), for example “a 54-year-old man with
abdominal pain may be diagnosed with appendicitis diabetes, coronary artery disease (CAD), and hyper-
and will require an appendectomy or the diagnosis is tension (HTN) who presents with . . .,” but you should
acute cholecystitis that will require a cholecystectomy. avoid this. The PMH is the section of the H&P used to
A surgical admission is one in which the patient is document the patient’s ongoing medical problems and
admitted at a pre-arranged time to have an elective, or conditions that affect the patient’s overall health status.
a planned, operative procedure to treat a specific known If a patient were admitted for pneumonia, it would be
condition, such as a nephrectomy for renal mass, joint important to document any respiratory conditions the
replacement for advanced arthritis, or surgical repair patient currently has or has had because the admitting
of a torn anterior cruciate ligament. problem is a respiratory system problem. Document
any chronic conditions the patient is being treated
Medical Admission History for that would have an impact on the patient during
and Physical Examination the hospitalization, especially diabetes, cardiovascular
Gone are the days when the patient’s primary care pro- disease, or cancer. Indicate if chronic problems are well
vider (PCP) admitted and followed a patient throughout controlled or uncontrolled. If the patient has had any
the patient’s hospital stay. These duties are now assumed type of surgery related to the CC, it is important to
by hospitalists or physicians who specialize in the include the date and time of the surgery in the PMH;
care of hospitalized patients. Hospitalists are usually otherwise, a list of all the surgeries the patient has had
board-certified internists, and they are responsible for in the past may not be important to document.
coordination of care of patients and communication Medication History
between members of the health-care team, including It is always important to document all medications a
the patient’s PCP. The admitting physician is responsible patient has been taking up to the time of admission
for completing the admission H&P. The content of an regardless of the reason for admission. Your documentation
admission H&P is much the same as a comprehensive should include complete drug information, including
H&P performed in an outpatient setting (see Table 2-1). the dosing unit, frequency of administration, and route
of administration. Likewise, it is always important to
Identification document any drug allergies. In some hospitals, patients
Identification information will include a unique numeric with drug allergies are given a special armband to wear
or alphanumeric identifier assigned to every hospitalized that alerts all caregivers to their allergies. The chart is
patient. The terminology of such an identifier may vary, often flagged or marked in some way to call attention
but it is often referred to as the medical record number. to any known allergies to avoid prescribing or admin-
The same identifier is used throughout the hospital stay istering a medication that the patient is allergic to or
and is often used for the same patient for each interaction a medication that is closely related.

Chapter 10 Admitting a Patient to the Hospital | 219
Health Maintenance and Immunizations address psychosocial concerns on the patient’s behalf.
It is usually not necessary to document health main- At some hospitals, you may need to write a specific
tenance information in an admission H&P because order to initiate these services.
the focus of the hospitalization is to treat and resolve Language and cultural barriers could have a dramatic
the current medical condition, and health mainte- impact on a patient’s hospital course. Under a number
nance is better addressed on an outpatient basis when of laws (see Medicolegal Alert!), hospitals must ensure
the patient is not acutely ill. It may be important to that there is no discrimination in patient care and that
include immunization status if pertinent to the CC; there is effective communication between health-care
in the case of a patient admitted for pneumonia, you providers and patients who are deaf or hard of hearing
should document whether the patient has had the or have any language barrier. The Office of Civil Rights
pneumococcal vaccination and when that was given. (OCR) has determined that effective communication
If a patient presents with abdominal pain and weight must be provided at “critical points” during the hospi-
loss, you should document if and when the patient has talization. Critical points include those points during
had a colonoscopy. which critical medical information is communicated,
such as at admission, when explaining procedures,
Family History (FH) when informed consent is required for treatment, and
The amount of family history (FH) that needs to be at discharge. Many electronic medical record (EMR)
documented in an admission H&P will vary according systems have a specific way to document interpretive
to the reason for admission. If a patient is admitted for services, such as the interpreter’s name and identification
pneumonia, FH is not likely to affect management of number, what type of service was used (i.e., on-site
the patient. If a patient is admitted because of acute interpreter or video remote interpreter), and what
substernal chest pain and the plan is to evaluate for language was used.
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 MEDICOLEGAL ALERT !
factors could affect your management of the patient.
The Department of Health and Human Services (HHS),
Social History (SH) Office for Civil Rights (OCR) is responsible for enforcing
It is important to document any history of tobacco, Title VI of the Civil Rights Act of 1964, which prohibits
drug, or alcohol use. Patients who smoke will be at risk discrimination based on race, color, and national origin,
for specific complications related to their smoking. If a and Section 504 of the Rehabilitation Act of 1973,
patient drinks alcohol on a daily basis, hospitalization which prohibits discrimination based on disability against
interrupts the intake of alcohol and puts the patient recipients of financial assistance from HHS. OCR is also
at risk for withdrawal. Abrupt cessation of other sub- responsible for ensuring compliance with Title II of the
stances may put the patient at risk for withdrawal, so Americans with Disabilities Act as it applies to health
documenting the substance use alerts you to monitor and human services as well as activities of state and
for changes in the patient’s condition that may signal local governments. This legislation requires hospitals to
withdrawal. If the patient is not able to make his or her provide interpreter services for non-English speakers
own decisions, you should document who is responsible or patients with other communication barriers. Using
for medical decision-making. A hospitalization can be a a family member or bilingual staff to interpret does not
major stressor, not only for the patient, but also for family fulfill the obligation for interpreter services and can result
members. If the patient is a caregiver for someone else, in inaccurate information exchange that can seriously
such as a spouse with dementia or a child with special impact the patient’s health. Legislation also requires that
needs, the concern about who will care for that person certain forms (such as a surgical consent form) and
often adds additional stress that can affect the patient’s patient education materials are available in languages
course of recovery. Other SH to document includes other than English. Hospitals must make “reasonable
what kind of help the patient may need at the time of accommodations” during a hospitalization to meet the
discharge; what support system, if any, is available to needs of any person who is disabled.
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 Review of Systems (ROS)
that may affect the patient’s nutritional needs during As a provider, you need to be aware of the CMS Guide-
the hospital stay. Ancillary personnel, such as social lines for E/M services when deciding how much of the
workers, discharge planners, nutritional counselors, review of systems (ROS) to document. This decision
and chaplains or clergy, are typically available to help will also be influenced by the patient’s overall medical

condition, the reason for the hospitalization, and the admission H&P because these results can be found
level of acuity. The higher the level of complexity of elsewhere in the medical record. Be sure to include
the E/M (see Chapter 1), the greater the need for any results that are most pertinent to the reason for
detailed documentation. If a 25-year-old man who hospitalization. If you identified multiple problems
has no significant past medical history is hospitalized in the Assessment section, then typically you would
for pain related to a kidney stone, the ROS could be document the abnormal results correlating to each
limited to general and genitourinary systems, and the problem. Using the example of a patient admitted with
E/M is straightforward. If a 75-year-old woman who pneumonia, it would be important to document that
has HTN, diabetes, hypothyroidism, and uterine cancer the chest x-ray confirms the presence of a right lower
presents with abdominal pain, the ROS will need to lobe (RLL) infiltrate, the complete blood count (CBC)
be much more comprehensive, and the E/M is much shows an elevated white blood cell count (WBC) of
more complex. At times, a patient’s condition may 13.7, and the differential indicates a left shift. In most
make it impossible to obtain any ROS (for instance, a cases, normal results are not documented in this section.
patient on a ventilator or with advanced dementia); in
such circumstances, you should always document why Problem List, Assessments, and Differential
an ROS was not obtained. Diagnoses
Two of the most important sections of the admission
Physical Examination H&P are those that contain the problem list, assess-
General Assessment ments, and differential diagnoses and that outline
The patient’s progress—or lack thereof—will be gauged the treatment plan. You would list the problem that
by change from his or her baseline at admission; necessitated hospital admission first as the admitting
therefore, documentation of the general assessment diagnosis. When a patient presents with a symptom,
is important to allow for this comparison. Describe such as chest pain, and you have not reached a definitive
the patient’s level of alertness; orientation to person, diagnosis, then state the problem or symptom followed
place, and time; ability to comprehend the situation; by a brief overview or explanation of why the patient
and reliability to provide the history. If someone other needs admission, as shown in Examples 10.1 and 10.2.
than the patient provides the history, document who
and his or her relationship to the patient. Describe the EXAMPLE 10.1
patient’s overall state of health, such as well-developed,
Chest pain, strong risk factors for cardiac etiology. Initial
well-nourished; frail and emaciated; or appears older than
cardiac enzymes are within normal limits (WNL). There
stated age. Documentation of the general appearance
is ST-segment elevation in the anterior leads; however,
should paint a picture of the patient at the time of
it is unclear whether these are acute changes.
admission so that someone reading the H&P who
has not seen the patient would be able to formulate
an image of the patient. EXAMPLE 10.2
Vital Signs
Multiple sets of vital signs may be documented in the Acute mental status change. Patient transferred from
admission H&P. If a patient presents to the medical long-term care facility because of confusion, hypoten-
floor at 15:00 and the H&P is performed at 17:00 the sion, and elevated WBC . Indwelling catheter in place
following day, it is appropriate to document the first with cloudy urine. Cultures are pending; urosepsis is a
set of vital signs that were obtained the afternoon of likely cause for these symptoms.
admission and then the vital signs obtained most re-
cently. Document the date and time that each set was After the initial problem or diagnosis, document any
obtained. Because care is provided around the clock significant comorbid conditions or other problems that
during a hospitalization, military time is typically may affect the patient’s course of treatment in the hospital.
used to avoid confusion between morning and evening In Example 10.2 of a patient with acute mental status
times. In an EMR, the vital signs often autopopulate change, a decrease in creatinine clearance signifying
into the record, so every recorded set of vital signs is renal insufficiency would be significant because renal
available for review. insufficiency could affect the choice of antibiotics and
could create problems with volume status. Comorbid
Laboratory and Diagnostic Test Results conditions typically documented in this section include
Documentation of laboratory data and other diagnostic HTN, diabetes, renal disease, any hematologic or onco-
studies should support the need for the hospitalization. logic problems, and any medical conditions that would
Not every test result obtained is documented in the require ongoing monitoring and treatment.

Plan use specially developed templates to document the

The Plan portion of the H&P outlines what care the admission H&P, such as the one shown in Figure 10-1.
patient will receive during the hospitalization. It is not Complex surgical procedures, or procedures performed
necessary to document every intervention that will be on patients with complex medical conditions, often
initiated but rather to provide an overview of treatment necessitate hospital admission to ensure adequate
because you will provide details of specific treatments pre-operative preparation and monitoring of the
in the admission orders. The plan corresponding to the patient’s postoperative progress.
examples could be documented as follows:
CC and HPI
EXAMPLE 10.3 Your documentation of the H&P for a surgical ad-
mission is similar to both a comprehensive H&P and
Admit to telemetr y. Continue thrombolytic therapy
an H&P for a medical admission; however, there are
that was star ted in the emergency depar tment (ED).
some important differences. You may state the CC as
Continue serial electrocardiograms (ECG) and cardiac a condition (“I have gallstones”), or the patient’s state-
enzymes. Consult cardiology. ment may reflect what operative procedure is planned
(“I am having surgery to remove my gallbladder”). The
EXAMPLE 10.4 HPI documents key events or findings that indicate
the need for surgical intervention.
Begin empirical broad-spectrum antibiotic therapy. Will
closely monitor patient’s intake and output and daily PMH
weights. Will hold off on vasopressor therapy at this In the PMH, you should document pertinent medi-
time, but it may be needed if patient becomes more cal conditions that would affect the hospitalization.
hypotensive. Specifically, document whether the patient has HTN,
diabetes, or any condition that is being treated with
Procedures that will be done during the hospital- corticosteroids or antiplatelet therapy because any
ization are documented in the Plan section sometimes, of these will require careful perioperative manage-
especially if more than one is needed and there could ment. Be sure to include a detailed surgical history,
be scheduling conflicts. If the admitting physician including any previous procedures, what type of an-
intends to obtain consultations with specialists, this is esthesia was used, and if any complications resulted
documented in the Plan section as well. At times, the from those procedures such as bleeding, malignant
Assessment and Plan sections may be combined into hyperthermia, or anesthetic complications. Document
one section. Examples of this are shown in some of whether the patient required transfusion of blood
the worksheets used in this chapter. In many EMRs, or blood products. As discussed previously in the
the format is determined by the system or by specific medical admission H&P section, be sure to include
document templates. Otherwise, it is usually the personal a complete medication list and documentation of
preference of the provider to document as one section any drug allergies.
or to combine; both ways meet CMS guidelines.
FH
Surgical Admission History and Physical Your documentation of the FH should include any
Examination known bleeding disorders that are genetic or have a
When a patient presents for elective surgery, the familial tendency. If the surgery were for a condition
admission H&P has often been done during a pre- that has a familial predisposition, such as certain types
operative office visit with the surgeon, and then the of cancers, you would document those conditions and
document is transmitted to the hospital for inclusion the family members affected as well.
in the patient’s medical record. Federal guidelines
state that an H&P completed up to 30 days before SH
admission is acceptable, but if it is not done within You should document the same details of the SH dis-
7 days of admission, there must be documentation cussed in medical admission H&Ps in a surgical H&P.
that the H&P was reviewed and that any changes in It is important to document any history of tobacco use,
the interim must be documented. Advances in surgical because this may affect respiratory function during
techniques allow for many procedures that previously surgery and recovery. Also document any alcohol use;
would have required hospitalization to be performed if the history suggests dependence or abuse, this should
on an outpatient basis. Many hospitals operate out- alert you to monitor the patient for withdrawal symp-
patient or same-day surgery centers, and some may toms. Additionally, if there is any consideration that

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
Figure 10-1 Sample same-day surgery H&P.

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a blood transfusion or administration of other blood Problem List, Assessments, and Differential
products might be needed during hospitalization, be Diagnoses and the Treatment Plan
sure to identify any factor that would affect the patient’s Typically, you would list the condition necessitating
willingness to receive such products. This is commonly surgical intervention first in the Assessment and prob-
seen when a patient is of the Jehovah’s Witness faith lem list section, followed by any comorbid conditions
and is not willing to accept transfusion of blood or that would require perioperative monitoring or that
blood products. could potentially give rise to postoperative complica-
tions. Documentation of the Plan section includes the
ROS
planned operative intervention and may also include
If not fully explored in the HPI, the ROS should focus specific pre-operative preparation, patient education,
on the system most closely related to the planned surgical consultations, and a general outline of postoperative care.
procedure. In the example of a patient being admitted
for cholecystectomy, you would document a detailed Sample H&P
gastrointestinal ROS. Inclusion of other systems or the Chapter 2 contains a sample comprehensive H&P for
level of review of other systems will be influenced by Mr. William R. Jensen (see Fig. 2-2) who presented in
the complexity of the planned procedure as well as the an outpatient setting to Dr. Scott and was evaluated for
type of anesthesia planned and any comorbid conditions fatigue and blood in the stool. Subsequent evaluation by
the patient may have. a gastroenterologist and surgeon led to the diagnosis of
adenocarcinoma of the colon. Using a case study format,
Physical Examination we will follow this patient’s care as he is admitted for
Documentation of the physical examination should surgical management. Figure 10-2 shows a sample
clearly establish the patient’s baseline pre-operative admission H&P for Mr. Jensen when he presents for
condition because postoperative assessment will surgical management. Compare Figures 10-2 and 2-2
focus on return to pre-operative functioning. Give to see how the comprehensive H&P is modified for a
careful attention to examination of the body area surgical admission H&P.
involved in the surgery. Many surgeries will be done Two sets of admit orders will be written for Mr. Jensen:
after administration of general anesthesia; therefore, his initial pre-operative admit orders and the initial
it is especially important to document pulmonary postoperative orders. We discuss documentation of
function. Examination of the upper respiratory sys- an admit note in this chapter. In Chapter 11, we will
tem should include the oropharynx, noting any loose follow Mr. Jensen’s care through documentation of the
teeth or dental work, such as partial or full dentures. operative report, an operative note, daily progress notes,
Lower respiratory system assessment should include and orders, and then conclude the hospitalization with
chest shape, symmetry of expansion with respiration, documentation of discharge orders and the discharge
diaphragmatic movement, respiratory effort, and the summary in Chapter 12.
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 Admission Orders
status, complexity of the planned surgical procedure,
estimated operative time, and anticipated postoper- When a patient is admitted to the hospital, the orders
ative course. written at the time of admission direct the health-care
team in caring for the patient. It is important that
Laboratory and Diagnostic Test Results the orders are completed in a timely manner and
Laboratory and other diagnostic studies are sometimes are unambiguous. Once written, an order is in effect
completed on an outpatient basis before the patient’s until another order is written to change or stop the
hospital admission. When this is the case, it is important original order, unless a time or dose limit is provided
to document pertinent results in the H&P, and a copy in the original order. For example, an order to record
of all results should be made part of the permanent intake and output would be carried out until an order
medical record. The need for baseline pre-operative is written to discontinue recording intake and output.
testing is correlated to the patient’s age, overall medical An order for Ancef 1 g IV every 8 hr × 3 doses will be
condition, and type of surgery the patient will have. given for only 3 doses; thus, it is not necessary to write
Some facilities have set policies, such as obtaining an an order to stop Ancef. However, an order for heparin
ECG in every patient 40 years of age or older and a 5,000 units SQ every 8 hours would be given every day
chest x-ray (CXR) in any patient who smokes or who that the patient is in the hospital unless the order is
is 50 years of age or older. specifically discontinued.

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.

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)
Author ISBN #
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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
Figure 10-2 Mr. Jensen’s admission H&P.

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At some facilities, it is acceptable to use precompleted of the order sets that
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order sets. These order sets are developed for conditions that from various
Artist disciplines, nursingDate staff, pharmacists,
03/06/18
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and
require hospital admission so often that the same orders sometimesABother health-care team members.
Check if revision An
Editor's example
review
would be written over and over, such as chest pain, rule of a precompleted
B/W 4/Corder 2/Cset Xis 2ndshown
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out acute myocardial infarction (AMI); cerebrovascular In facilities that(Width

Final Size useX Depth
EMR, usually you will be able
in Picas) to
Date
accident (CVA); or pre-operative care. In facilities where create your ownx order
40p12 43p3 sets. There are severalInitials mnemonics
precompleted orders are used, there is usually an estab- that may be used to help you remember what should be
lished protocol for development, review, and acceptance included in admission orders. One mnemonic is AD

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:
Treatments:
Arterial Line:
Small-volume nebulizer orders: __________________________________________________________________________
Additional Orders:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Physician Name - Print and Sign Date Time
Figure 10-3 Pre-operative order set.

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CAVA DIMPLS, which stands for Admit, Diagnosis, documented as critical. If a patient is having crushing
Condition, Activity, Vital signs, Allergies, Diet, Inter- chest pain and is diaphoretic with an irregular heart
ventions, Medications, Procedures, Labs, and Special rate, the condition might be documented as unstable.
instructions. Each component is described in more detail Other words commonly used to describe condition are
and an example of each is provided. Figure 10-4 presents stable, guarded, moribund, and comatose.
the mnemonic in a condensed form.
Activity
Admit Indicate the level of activity the patient is permitted
Specify the admitting physician and the hospital unit to have. There are several activity orders commonly
to which the patient should be admitted. Admit to used; the condition of the patient (including mental
Dr. Johnson to the orthopedic floor or Admit to Dr. Myers alertness) and the overall health condition of the patient
to telemetry unit. determine which order is most appropriate. Common
activity orders include the following:
Diagnosis
State the admitting diagnosis and, in the case of a • Up ad lib (the patient may be out of bed as he or
surgical admission, include the name of the procedure she wishes)
to be performed. When a patient has more than one • Activity as tolerated (whatever the condition
admitting diagnosis, be sure to list the problem most allows the patient to do)
responsible for admission as the primary diagnosis. • Bedrest with bathroom privileges, abbreviated as
If there are any comorbid conditions that should be BR with BRP (allowed out of bed to go to the
monitored during the hospital stay, document them bathroom; otherwise in bed)
as additional diagnoses. Primary diagnosis: pneumonia. • Out of bed (OOB)
Secondary diagnosis: type 2 diabetes. • Ambulate a certain number of times a day
• Ambulate with assistance
Condition • Non–weight-bearing
This reflects the patient’s condition at the time of
admission based on overall appearance, vital signs, and Vital Signs
severity of injury or illness. If a patient has multiple This order reflects how often the standard vital signs
injuries from a motor vehicle crash and is semicon- (VS) (temperature [T], heart rate [HR], respiratory
scious with unstable vital signs, the condition might be rate [RR], and blood pressure [BP]) should be obtained
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)
Figure 10-4 Admission orders mnemonic.

and will vary according to the patient’s condition. Some by mouth. If allowing the patient to eat does not pose a
hospitals have standing orders for VS depending on the threat to safety, there are many dietary orders that you
type of unit or floor to which the patient is admitted. can write. It is not possible to include all the dietary
Critical or intensive care units almost always have orders in this text; some of the more common types
their own standing orders. Some VS are monitored of diets are shown in Table 10-1. Consultation with a
continuously as the patient’s condition warrants; for dietitian is usually an option. Often hospitals will have
instance, BP and HR are monitored continuously in a a dietary manual available for review as well.
patient who recently had a myocardial infarction. Typical
orders for medical admissions are VS q8h while awake Interventions
(if the patient is very stable and if it is not necessary to This refers to interventions by nursing or other ancillary
awaken a patient to obtain VS) and VS q4h. staff, such as physical therapy or respiratory therapy. One
Generally, weight is obtained only at the time of example of an intervention is single volume nebulizer
admission. If a patient’s condition necessitates moni- (SVN) with 0.5 mL albuterol in 2.5 mL normal saline
toring of volume status or renal function as in the case (NS) q4h. Another example is Physical therapy (PT)
of heart failure, edema, or fluid retention, write an order to evaluate and treat. Intravenous (IV) therapy is also
to weigh daily. considered an intervention. If you write an order for
IV therapy, you should specify the type of fluid and the
Allergies rate of administration, such as D5NS (5% dextrose in NS)
This is not actually an order but rather a specific no- at 80 mL/hr. (Consult the Bibliography for suggested
tation of allergies that the patient may have to any readings related to principles of IV therapy.)
medication, food, or other substance. It is customary
to include the specific agent the patient is allergic to Medications
and what reaction the patient has to the agent. One Unfortunately, medication errors and adverse drug
way to note this is Allergic to penicillin (rash) and aspi- events are common during a hospitalization. The impact
rin (dyspnea). You may find some providers document of these events on patient welfare and the financial
the details of the reaction in the PMH section of the burden, both to the patient and the health-care system,
admission H&P and list the drugs only in the orders; are significant. In 2005, The Joint Commission put
this is an acceptable practice. If it is hospital policy to forth medication reconciliation as National Patient
identify patients with allergies by a special armband Safety Goal (NPSG) No. 8 in an effort to minimize
or other designation, then it is not necessary to write adverse events at point of care transitions. Medication
a specific order for this. reconciliation is the process of comparing a patient’s
Diet medication orders to all of the medications that the
patient has been taking. This reconciliation is done to
The first step in deciding what type of diet to order
avoid medication errors, such as omissions, duplica-
is usually to determine whether it is safe to allow the
tions, dosing errors, or drug interactions. This process
patient to eat. If the patient is going to have surgery or
comprises five steps:
a procedure that requires sedation and, therefore, car-
ries a risk for aspiration, or if a patient is not mentally 1. Develop a list of current medications (includ-
alert enough or physically able to eat and swallow, it ing prescription medications, over-the-counter
is safer for the patient not to receive any nourishment medications, herbals, vitamins, and nutritional
by mouth. The order for this is NPO, an abbreviation supplements).
for the Latin phrase nil per os, interpreted as nothing 2. Develop a list of medications to be prescribed.
Table 10-1 Common Diets for Oral Intake

Condition Dietary Intervention Typical Order
Diabetes Restrict sugars and fats; follow 45 grams carbohydrate
recommendations of the American 60 grams carbohydrate
Diabetes Association
Hypertension, kidney disease Salt restriction Low-sodium diet, 2 g Na+ diet
Coronary artery disease or Fat and cholesterol restriction Cardiac diet; heart healthy diet; low-fat, low-
hypercholesterolemia cholesterol diet, National Cholesterol Education
Program Step Two diet
Unable to chew well, ill- Allow soft foods only Soft mechanical diet
fitting dentures

3. Compare the medications on the two lists. Laboratory and Other Diagnostic Studies
4. Make clinical decisions based on the comparison. It may be necessary to monitor certain laboratory values
5. Communicate the new list to the patient and to or obtain diagnostic studies as part of a patient’s care.
appropriate caregivers. For instance, when a patient is on an anticoagulant
Because additional medications are likely to be pre- medication, you monitor the bleeding time. If a patient
scribed during the hospitalization, you must complete develops fever and a cough, you might order a CXR. You
a thorough medication reconciliation at the time of should always have a rationale for ordering laboratory
admission so you and the pharmacy staff can determine or other diagnostic studies. If a patient had surgery but
whether drug–drug interactions or drug–disease inter- had very little intra-operative bleeding, it is unnecessary
actions could occur. With that in mind, always specify to order H&H (hematocrit and hemoglobin) q am; you
the name of the medication, the dose, the route, and would not expect the values to change because there was
frequency of administration (see Chapter 9, Elements little blood loss. When ordering imaging studies such
of a Prescription section). It is common to write orders as x-rays or computed tomography (CT), you should
first for any medications that are given for the condi- include the indication for the study, not only to aid
tion necessitating hospitalization, then orders for any in the interpretation of the study but also to establish
medications taken before hospitalization that need to the relevance of the study to the patient’s overall care.
be continued, and then orders for any symptomatic An example is AP (anteroposterior) & lateral CXR to
medications. evaluate for pneumonia.
Symptomatic medications are those that may or may not
be needed. During a hospitalization, patients experience Special Instructions
sleeplessness, constipation, pain, and nausea with such The rationale for special instruction orders is to ensure
frequency that typically orders are written at the time that nursing staff informs you of changes in a patient’s
of admission so that medications are available to treat condition that may require some intervention. For
these symptoms if they develop. Not only will these instance, results of glucose monitoring above or below
orders reduce discomfort for the patient, they will also a certain level may require withholding, increasing, or
prevent nursing staff from having to call you at 2:00 to decreasing insulin doses. You would write an order
request a sleep aid. You would order these medications to Notify Dr. Wattanapanit if blood sugar is less than
on an as-needed (or PRN, Latin for pro re nata) basis, 100 mg/dL or greater than 350 mg/dL. If a patient was
and they would be administered only as requested by admitted two days ago for AMI and now has new onset
the patient. If you write an order for a PRN medication, of atrial fibrillation, you want to be alerted to that fact.
you always want to include the indication for giving the You should never assume that the nursing staff will notify
medication. An order written as morphine 2 mg IV PRN you automatically of such developments. As a general
is open for interpretation. Although the nursing staff rule, they probably would; however, the responsibility
would recognize that morphine is a narcotic analgesic of managing changes in the patient’s condition rests on
and would know that it is given to relieve pain, the order the attending medical staff—not the nursing staff—and
is ambiguous. Instead, it should be written with specific you can manage only what you are aware of. Writing
dosing, frequency, and indication instructions, such as the special instruction order protects you as a clinician
morphine 2 mg IV q2h PRN mild pain. This prevents the and helps to ensure the best treatment for the patient.
medication from being administered for reasons other
than pain and establishes a safe time frame in which
the medication may be administered. Always order Perioperative Orders
a specific dose, rather than a range of dosing such as
morphine 2–6 mg IV q2-3h PRN pain. This helps prevent Perioperative is a term that is used to refer to all three
inappropriate administration of the medication. phases of surgery (pre-operative, intra-operative, and
postoperative). When a patient is admitted for sur-
Procedures gery, the initial pre-operative orders are in effect until
Many routine procedures are part of a patient’s daily the patient goes to surgery. Pre-operative orders for
care, and it may seem intuitive that these procedures Mr. Jensen are shown in Figure 10-5. After surgery, the
should be performed. However, writing an order for patient goes to the postanesthesia care unit (PACU),
such procedures as daily catheter care, wound or ostomy sometimes referred to as the recovery room. While the
care, and dressing changes provides justification for patient is there, the staff generally follows prewritten
performing these procedures and allows the hospital PACU orders, like those shown in Figure 10-6. Once the
to charge for the necessary supplies. The order should patient is awake, maintaining an airway with adequate
specify how frequently the procedures should be carried respirations and has stable vital signs, the patient is
out, such as dressing change three times daily. essentially re-admitted to the hospital and a new set of

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: _______________________________________________
Countersignature: _____________________________________________
Figure 10-5 Pre-operative admit orders for Mr. Jensen.
postoperative orders must be written. We use the same after surgery, but you must take into consideration
mnemonic provided earlier, AD CAVA DIMPLS, to the type of surgery and the patient’s overall condition
write the postoperative orders for Mr. Jensen. when determining the activity level. An activity order
for Mr. Jensen could be OOB three times a day (TID)
Admit with assistance.
The patient is typically admitted to the surgeon.
Vital Signs
Diagnosis In the immediate postoperative period, vital signs are
The postoperative admitting diagnosis is usually the obtained progressively. A common postoperative order is
condition that required surgical intervention, and it VS qh x 4; if stable, then q2h x 4, then q4h. An order such
may include the type of procedure done. For instance, as this reflects the possibility that a patient’s condition
Mr. Jensen’s admitting diagnosis could be written as might change in the immediate postoperative period
colon cancer, status post (S/P) hemicolectomy. and that more frequent assessment is needed initially,
but if the patient’s vital signs remain stable, then less
Condition frequent assessment is permitted.
Condition refers to how the patient is doing immediately
after surgery when the postoperative orders are written. Allergies
Any allergies should be noted in the orders.
Activity
When writing the activity order, keep in mind that Diet
postoperative patients usually require at least some Surgical patients usually have special dietary needs in
narcotic pain relief, which may impair judgment or the postoperative periods. The type of surgery and the
function. Safety precautions may be indicated, such as type of anesthesia usually determine the type of diet
side rails up at all times or ambulate only with assistance. ordered. When a patient undergoes surgery involving
To prevent complications associated with immobility, the gastrointestinal
Author
tract, ISBN
often
#
paralyzing agents are
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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.
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
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 _____________
Oral Agent: _________________________________________ Oral Agent: ____________________________________
Other: _____________________________________________ Other: ________________________________________

Discharge when criteria of Aldrete score greater than or equal to 8 is met or per physician order.
Other:
Fingerstick for glucose as needed
Other: _______________________________________________________________________________________________
** DISCONTINUE MEDICATION ORDERS ON THIS PAGE WHEN TRANSFERRED TO NURSING UNIT **
Physician Name - Print and Sign - To Activate Only Orders Checked Above Date Time
Figure 10-6 PACU orders.

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such as age, mobility, and overall health status affect how liquid, soft, and regular diets. You may find that some
quickly bowel function returns after surgery. Patients practitioners prefer to write an order to advance diet as
are often kept NPO until bowel function returns. Once tolerated and not specify when to advance the diet or
bowel function resumes, indicated by the return of bowel what type of diet to follow, leaving the details to the
sounds or passing of flatus, you can advance the patient’s judgment of the nursing or dietary staff.
diet from liquids to solids as tolerated. Typically, the
initial diet order is clear liquids. If the patient is able to Interventions
tolerate clear liquids without any nausea or vomiting, Like any patient who has had abdominal surgery,
then the diet is advanced to full liquids and then to a Mr. Jensen is likely to have shallow respirations post-
regular diet or any special diet indicated for specific operatively, which puts him at risk for pulmonary
medical conditions. Table 10-2 provides information complications. To prevent such complications, an
about the liquids and foods allowed on clear and full important intervention order for Mr. Jensen is incentive
spirometry (IS) 10 times per hour while awake. Another
Table 10-2 Diets Commonly Used in the important intervention is maintaining hydration and
Postoperative Period nutrition. Until adequate oral intake is possible, IV
fluids should be administered. For Mr. Jensen, we will
Type of Diet Foods Allowed order D5NS @ 120 mL/hr.
Clear Liquid Diet
Often prescribed Broth Medications
for a short Gelatin Mr. Jensen will require some medications. Medications
period after
surgery to give
Tea administered orally may be withheld until bowel func-
gastrointestinal Popsicles tion returns. Symptomatic medications are indicated,
tract a rest Clear juices, such as apple, especially for pain and nausea. Specify not only the
cranberry, or grape name of the medication but also the dose, route, and
Clear sodas, such as lemon-lime frequency and the indications for any PRN medications.
or ginger ale
Some hospitals require the use of generic drug names,
Coffee may be allowed with
physician approval whereas others accept generic or trade names. Check
Full Liquid Diet with the hospital pharmacy to be sure which you should
Prescribed as a All the foods shown for clear use. A common option for managing postoperative pain
transition from liquid diet plus: is a patient-controlled analgesia (PCA) system. This
clear liquid to a Milk refers to an electronically controlled infusion pump
soft or regular diet Yogurt that delivers a prescribed amount of IV analgesic to a
Pudding patient when the pump is activated. Use of PCA has
Milkshake, ice cream, sherbet been shown to reduce the time between when a patient
Smooth cream soups feels pain and when the analgesia is delivered. It also
Oatmeal, cream of wheat, grits, reduces the chances for medication errors because
gravy the PCA is programmed per the physician’s order for
Dark sodas, such as colas specific doses and time intervals between doses. There
Juices with pulp, such as orange, is also a “lock-out” feature that prevents overdosing.
grapefruit, pineapple Figure 10-7 shows an order set for PCA.
Soft Diet An anti-emetic drug is usually ordered as a PRN
May be prescribed if Oatmeal medication. Nausea is common in the postoperative
patient has a sore Mashed or baked potatoes period, and anti-emetics can reduce nausea and prevent
throat following Bananas
endotracheal vomiting. Most anti-emetics potentiate the action of
intubation or Scrambled eggs narcotic analgesics, so frequently they are administered
dental problems Soft bread or rolls (not toasted) together. However, you would order the analgesics and
Applesauce anti-emetics separately so that they may be administered
Gelatin individually if both are not needed.
Puddings Once bowel function returns, Mr. Jensen’s pre-operative
Regular Diet medications should be restarted. It is also desirable to
Similar to what most Most foods are allowed; change from parenteral to oral analgesics when the
patients would moderate in salt, sugar, and fat patient can tolerate oral intake. In fact, the patient’s
consume at home Specific foods not allowed will
ability to obtain effective pain relief from oral analgesics
vary by facility; consult with dietary
and nutritional support personnel and return to oral intake of liquids and foods is often
considered criteria for discharge.

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
_____ mg (2–4 mg) IV every 15 ______ mg (0.2–0.6 mg) IV every 15 ______ mcg (10–40 mcg)
Loading Dose 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.
______ mg (1–2.5 mg [1 mg*]) ______ mg (0.2–0.4 mg [0.2 mg*]) ______ mcg (10–25 mcg
PCA Demand Dose [10 mcg*])
______ min (6–15 min [12 min*]) ______ min (6–15 min [8 min*]) ______ min (4–8 min
Lockout Interval [6 min*])
Ranges marked with * are recommended for opioid-naive patients

4-hour Limit ______ mg (15–30 mg) ______ mg (4–8 mg) ______ mcg (100–200 mcg)
______ mg every ______ hours ______ mg every ______ hours ______ mcg every ______
Bolus Dose
hours
Restricted to opioid-tolerant patients
Basal Rate
(optional) ______ 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*])
Doses shown in parentheses are for reference only—patient’s needs may require more or less than shown
Supplemental PCA administration instructions:
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
Adjunct medications (may continue for 24 hours following discontinuation of PCA)

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: _______________________________________________________________________________________________
Figure 10-7 PCA order set.
Procedures is not removed, you are required to document the reason

One procedure indicated for Mr. Jensen is daily wound why, such as need for accurate intake and output (I&O)
care. Order daily catheter care if the patient has an in- monitoring or surgery involving the genitourinary tract.
dwelling urinary catheter. Catheter-associated urinary
tract infections are a major concern for hospital patients, Laboratory and Other Diagnostic Studies
and many EMR systems have an automatic order to Often laboratory studies are indicated in the postoperative
remove any indwelling urinary catheter the first post- period to help monitor for potential complications. A
operative day unless otherwise ordered. If the catheter CBC is Author
often ordered to monitor
ISBN # the WBC count and
Author's review
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the H&H. You may order various chemistry panels, such

as a basic metabolic panel (BMP), to monitor electro-
Computerized Physician
lytes. Your order should indicate when the studies are Order Entry
to be done and for how many days, such as CBC daily
x 3 days with routine morning labs or H&H stat, then Even before the publication of the Institute of Medi-
every 8 hours x 24 hours. cine’s report To Err Is Human: Building a Safer Health
System (Kohn et al, 2000) identified an unexpectedly
Special Instructions high error rate in medical care, health-care providers
Some special instruction orders might be prudent for recognized that the rate of medication errors and ad-
Mr. Jensen. Because he has a history of HTN and verse drug events (ADEs) in hospitalized patients was
usually takes antihypertensive medication, you would unacceptably high. Since the report, awareness of the
want to know whether his blood pressure was elevated potential for severe harm from medication errors and
above an acceptable level. Likewise, development of a of the frequency of ADEs has increased dramatically.
fever would be important, and you would want to be Studies conducted after publication of the report con-
notified if that occurred. When a patient is admitted cluded that a great number of medication errors and
under the care of a surgeon, there is often a need to ADEs were preventable. One step that can be taken
obtain consultation with the hospitalist so he or she can to reduce errors is to avoid using certain dangerous
manage the patient’s medical conditions; therefore, an abbreviations, acronyms, and symbols when writing
order must be written for that consultation or any others orders; in fact, since 2004, The Joint Commission has
that might be needed. A complete set of postoperative required organizations to have a “Do Not Use” list. The
orders for Mr. Jensen is shown in Figure 10-8. Institute for Safe Medication Practices (ISMP) also
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. D51/2 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: ______________________________________________________________
Figure 10-8 Postoperative orders for Mr. Jensen.

provides a list of Error-Prone Abbreviations, Symbols CPOE, studies have reported a reduction up to 70% in
and Dose Designations, which is shown in Appendix C. medication errors (Devine et al, 2010) and a significant
The increasing concerns for safety and the desire for decrease in medication orders that were inappropriate
reducing and preventing medication errors have resulted (Mattison et al, 2010). The average time from medica-
in adoption of Computerized Physician (or Provider) tion ordering to administration decreased from 100 to
Order Entry (CPOE) in many hospital systems. 64 minutes (Cartmill et al, 2012). The costs of avoiding
Osheroff and associates (2012) define CPOE as “the ADEs ranged from $7 to $16 million (Zimlichman
portion of a clinical information system that enables a et al, 2013), and the incidence of duplicated orders
patient’s care provider to enter an order for a medica- decreased by 84.8%, resulting in additional cost savings
tion, clinical laboratory or radiology test, or procedure for the institution (Magid et al, 2012). According to the
directly into a computer that then transmits the order results of the 2016 Leapfrog Hospital Survey, 1,394
to the appropriate department, or individuals, so it can (75%) hospitals reported using a CPOE system in at
be carried out.” least one inpatient unit, compared with 384 in 2010.
Benefits of CPOE Challenges and Barriers to CPOE
Bobb and colleagues (2004) found that of 1,111 pre- One particular challenge associated with CPOE is selec-
scribing errors confirmed in their study, 65% were likely tion error. When a medication order is entered, usually
preventable with a basic CPOE system. Other studies the computer system will display a list of drug names
report preventable errors in the range of 43% to 72%. after a few letters have been entered. For example, if you
The number of potential preventable errors that was enter the letters m-e-t, medications such as Metamucil,
identified increased when basic CPOE was used in metformin, methadone, metaxalone, methyldopa and
conjunction with the Clinical Decision Support System metoprolol may show up on a selection list (Fig. 10-9a).
(CDSS). CDSS consists of automated checking to: Then you select the desired medication, but it is easy to
inadvertently select the wrong drug name. Once a drug
• Identify potential drug dose, allergy, and interac-
is selected, common doses will populate (Fig. 10-9b).
tion errors.
You must be cautious to select the correct medication
• Notify of duplicate orders.
and dose. Another challenge associated with CPOE is
• Recommend pre-administration or postadminis-
“alert fatigue.” The CDSS is designed to alert the pro-
tration tests.
vider when there are potential drug–drug interactions,
• Provide access to clinical reference information,
drug contraindications, drug–disease interactions, and
research, and guidelines.
drug allergies. Alert fatigue is caused by a combina-
• Substitute medication and test recommendations.
tion of critical medical alerts and a high volume of
Some CDSSs can also monitor patient treatment, marginally medically consequential alerts. Redundant
ensuring, for example, that the right drug is adminis- alerts can reduce providers’ sensitivity to the alerts,
tered to the right patient at the right time and can issue resulting in the provider dismissing the alert without
an alert or reminder and suggest a different course of actually investigating the concern, thereby increasing
treatment if a patient’s condition changes or if test results the opportunity for patient safety error.
are abnormal. Most CDSSs can provide health-care When EMRs were initially introduced, many systems
professionals with immediate electronic access to their did not include CPOE. Implementing a CPOE system
orders and comprehensive views of patient clinical data is always a challenge, and several barriers to CPOE use
and laboratory test results, allowing providers to make have been identified. CPOE has a considerable impact
more informed decisions about medications. Studies on work flow for health-care providers and hospital
of usage of CPOEs in major hospitals have found cost staff. Issues with interoperability with the EMR and
savings, increased use of preventive care interventions, CPOE systems are barriers to implementation. The
and improved clinical care. The literature supports the time required to train providers and staff is substantial.
beneficial effect of CPOE in reducing the frequency of Often, any pre-existing order sets must be modified or
a range of medication errors, including serious errors completely restructured for the CPOE system, which
with the potential for harm. CPOE integrates the med- is a labor- and resource-intensive process. Functional
ication order with patient information, such as allergies, problems often arise, so the availability of technical
laboratory results, and other prescription data. Then support is critical in implementing and ongoing use
the order is checked automatically for potential errors of CPOE. Because of the nuances and complexities of
or problems, such as drug and allergy interactions or the health-care environment, the standard information
drug-to-drug interactions. CPOE systems also suggest technology (IT) staff may not be able to resolve issues
default values for drug doses as well as routes and with CPOE function, and often they need input directly
frequency of administration. After implementation of from health-care providers and other staff to understand

A

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B
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.
10_Sullivan_Ch10.indd 236 Author ISBN # 7/4/18 3:42 PM

Author's review
work-flow issues and the medical significance of various service. If a voice recognition system is used to generate
processes. Appropriate support must be available around the H&P, the document is saved into the EMR right
the clock, 365 days a year, which often results in hiring away, and then an admit note is not needed.
more staff at expense to the institution. Because of the The admit note is a permanent part of the medical
continuous introduction of new medications, changes record. As such, it should be thorough enough to com-
in indications or contraindications for medications, municate the reason for the patient’s hospitalization and
and availability of new diagnostic tests, regular system should include the presumptive diagnosis and treatment
updates must occur, resulting in ongoing training for plan, but keep in mind that it is a brief summary of the
system users and support staff. Every upgrade has the H&P. An admit note typically contains the patient’s
potential to disrupt work flow and impact functionality, identifying information, reason for admission, pertinent
which, in turn, may impact patient safety. Especially past medical history, medications, allergies, pertinent
for small and rural hospitals, the cost of implementing findings from the physical examination, pertinent lab-
CPOE is a considerable barrier; cost for a very basic oratory data, admitting diagnosis, and a summary of
CPOE system starts at around $1.5 million; in larger the treatment plan. It is usually written as a narrative
hospitals, the cost may be more than $10 million. paragraph. Example 10.5 shows an admit note.
EXAMPLE 10.5
Admit Notes Admit note: S.B. is a 72-year-old woman who devel-
oped symptoms of fever and cough 2 days ago and has
Records such as admission H&Ps, operative reports, and
had progressive dyspnea. Her past medical histor y is
discharge summaries are sometimes dictated, resulting
significant for chronic obstructive pulmonar y disease
in a delay between the time of dictation and when
(COPD) and HTN. She takes Accupril 10 mg daily and
the transcribed record appears on the chart or in the
uses a Combivent inhaler twice daily. On physical ex-
EMR. Because of this delay, it is customary to write a
amination, she is febrile and dyspneic but not cyanotic.
brief admit note. The purpose of the admit note is to
Crackles are heard in the right posterior lung. Hear t is
summarize the admission H&P and to provide infor-
tachycardic but regular, with a rate of 112. Chest x-ray
mation that will be needed to care for the patient until
reveals an RLL infiltrate. Presumptive diagnosis is RLL
the dictated records get to the chart. Document that
pneumonia. S.B. is admitted to the medical ser vice for
an admission H&P has been performed and dictated,
IV antibiotic therapy and suppor tive respirator y care.
indicating the date and time it was done. This informs
H&P done and dictated 8/22/XX, 1543; job ID 1564273.
other medical staff members that the H&P has been
Rachel Alford, MD
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 Referring to the information found in the H&P for
number or report identifier; this should be documented Mr. Jensen (see Fig. 10-2) and the admit note shown in
as well in case dictations are lost or there is interrupted Example 10.5, write an admit note in the space provided.


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.
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
Summary impact on the entire hospital stay. You must give

meticulous care and attention to documenting the
Hundreds of thousands of hospital admissions occur admission H&P and generating orders, especially when
annually in the United States. Often patients are over- orders relate to medication administration. CPOE and
whelmed and feel vulnerable when faced with a hospital CDSS are designed to assist health-care providers in
stay. You as a provider can have a positive impact on successfully completing these tasks and have helped
patients and their health, yet you also are vulnerable reduce the number of medication errors and ADEs, yet
because you must navigate sometimes complex EMR there are still barriers to CPOE use. To reinforce the
systems to document patient care appropriately and content of this chapter, please complete the worksheets
continually evaluate and manage complex medical that follow. And be sure to review Appendix A, the
conditions. The admission process presents unique Document Library, for full case examples of patient
challenges for the health-care team and has tremendous documentation.

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?

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.

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.
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.
Figure 10-10 Admission H&P for C.H. Author ISBN # Author's review
240 Copyright © 2019 by F. A. Davis
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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.

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.
A:
D:
C:
A:
V:
A:
D:
I:
M:
P:
L:
S:

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.

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?

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.

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.
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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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.
Figure 10-11 Admission H&P for G.M.
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?

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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.
A:
D:
C:
A:
V:
A:
D:
I:
M:
P:
L:
S:

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.

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 AMI
AD CAVA DIMPLS AP
BMP BP
BR BRP
CAD CBC
CC CDSS
CMS COPD
CPOE CT
CVA CXR
D5NS ECG
ED E/M
EMR FH
H&H H&P
HHS HPI
HR HTN
I&O IS
ISMP IT
IV NPO
NPSG NS
OCR OOB
PACU PCA
PCP PMH
PRN PT
RLL ROS
RR SH
S/P SVN
T TID
VS WBC
WNL

Chapter 11
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.
Subjective information includes the patient’s own

Introduction comments or complaints as well as comments made
by family members or other health-care providers.
Completing the admission history and physical examina-
Objective information includes a general assessment,
tion (H&P) and writing the admit note and admission
pertinent findings from the physical examination,
orders is generally the most time-intensive part of the
and review of laboratory or diagnostic test results;
hospital stay for you as the admitting provider. While
it may include measurements, such as vital signs or
a patient is in the hospital, you or a designee must visit
intake and output (I&O). Assessment data are used
the patient daily. This is often referred to as “making
to document the patient’s response to therapy and
rounds” or “rounding on a patient.” The purpose of
how the patient is progressing as well as to identify
the daily visit is to see how patients are responding
any new problems. When applicable, documentation
to therapeutic interventions, communicate results of
also must include any complications, hospital-acquired
laboratory or other diagnostic studies, discuss the on-
infections, and unfavorable reactions to drugs, including
going treatment plan, and determine whether any new
anesthesia. The plan outlines any changes needed in
problems have arisen. Some of the content documented
the present plan of care or initiates therapy for any
in a daily progress note will be determined by whether
new problems.
the hospitalization is for a medical or surgical condition
(discussed later); however, there are commonalities that Content of a Daily Progress Note
would apply to either.
Medical Admissions
Subjective
Daily Progress Note Remember that documentation of an admission H&P
is required within 48 hours of hospitalization although
There may be specific progress note templates in the some institutions may have different requirements
facility’s electronic medical record (EMR). If not, for the time to complete. Some institutions require
or if the charting is paper based, you may use the documentation to reflect how many days the patient has
SOAP note format introduced in Chapter 3 to record been hospitalized, noted as “hospital day (HD) # ___”;
information that you gathered during the daily visit. some EMRs will display this automatically. The daily
257

progress note does not need to contain information with visitors, you might wonder about his or her
already documented in the H&P; instead, it focuses statement of having severe pain. On the other hand,
on any changes that have occurred in the condition of if the patient is lying curled in a fetal position, has
the patient from one day to the next. It is sometimes the lights off, and is grimacing or moaning, this is
helpful to ask the patient a general question, such a different assessment altogether. You are not likely
as, “Do you feel better, worse, or about the same?” to recall the details of the patient’s presentation, so
The answer to this question provides the patient’s document your observations. Vital signs are monitored
perspective on his or her response to treatment and and recorded at different intervals during a 24-hour
allows for comparison of how you think the patient period, depending on the frequency ordered. Some-
is progressing. Document the continued presence or times, you may summarize a range of results (e.g., pulse
resolution of any symptoms that the patient had at 80 to 104 in past 24 hours) or, for temperature, the
the time of admission. For example, if a patient was maximum result, in the note. In the EMR, vital signs
admitted for treatment of urosepsis and had fever and usually autopopulate into the record. How much
dysuria at the time of admission, document whether physical examination you do depends largely on the
the patient still has these symptoms. To assess the reason for admission and your medical discipline.
patient’s response to treatment or a procedure, you A patient being treated for a cerebrovascular accident
should anticipate what changes would be expected. The who has comorbid conditions would require more
patient with urosepsis who is treated with antibiotics extensive examination and, therefore, documenta-
should become afebrile with corresponding decrease tion, than a patient admitted for pneumonia who is
in the white blood cell (WBC) count, and you would otherwise healthy.
expect the patient to have less dysuria. The patient It is essential to document review of all test results
should be monitored for development of symptoms in a timely manner because missing an abnormal result
that might indicate an adverse reaction to treatment. could have a negative impact on the patient’s condition.
In the case of antibiotic administration, development You may use “shorthand” for documenting results of
of rash and difficulty breathing might indicate an a complete blood count (CBC), electrolytes, or basic
adverse reaction, so the presence or absence of these metabolic panel (BMP) (Fig. 11-1) in the paper-based
symptoms is a pertinent positive or negative. In addi- daily progress note. This provides a way to compare
tion to information that is obtained directly from the the newest results with previous ones. In the EMR
patient, the subjective portion could include review of format, usually the results are autopopulated each day;
notes from nursing staff, ancillary services personnel, some systems have a way to indicate that the results
or consulting providers as well as comments from staff were reviewed, but if not, you should document this
or family members. As discussed in Chapter 10, if an specifically. Typically, you would be able to view results
interpreter is used for any part of the visit, be sure to outside of the note, and you can select a date range
document the name of the interpreter, identification to see if there are previous study results available for
number, modality (i.e., on-site or video remote inter- comparison. Other objective information available to
preting), and the language. If the patient is not able to you are the notes written by other providers and staff;
provide information because of clinical condition or when you review others’ notes, be sure to document
advanced dementia, and so on, you should document this as well.
this specifically as well as documenting how you ob- Assessment
tained any subjective information, such as from family The Assessment section should reflect your evalu-
members, staff, or review of records. ation of all the data available and any conclusions
Objective that you could draw from them. The assessment
You will perform at least some physical examination should indicate whether the patient’s condition is
during each daily visit. It is always important to docu- better, worse, or about the same since the last visit.
ment the general assessment, providing a comparison If a patient was febrile at the time of admission but
to when you last saw the patient. It is easy to overlook is now afebrile, your entry might read, Patient now
the importance of performing or documenting the afebrile; improved. If any new problems have been
general assessment. When documenting the general identified, you need to document them. When the
assessment, consider what would be important to patient has certain comorbid conditions, such as
know about the patient’s presentation one year from hypertension or diabetes, typically you will include
now with just your documentation as a memory aid. these conditions in the Assessment section even if
If a patient is complaining of severe pain not relieved not the reason for hospitalization, and you would
by pain medication but is sitting up in the bed, alert document your assessment of the condition, such as
and smiling, watching television, and conversing well controlled or stable.

Chapter 11 Documenting Inpatient Care | 259
CBC
Hemoglobin Segs/bands/lymphs/monos/basos/eos
WBC MCV/MCH/MCHC
Hematocrit Platelet count
Example:
16 56 S/4 B/30 L/4 M/1 B/3 E
5800 82/29/34
48 259,000
Electrolytes
Sodium Chloride
Potassium Bicarbonate
Example:
138 97
4.2 23
Comprehensive Metabolic Panel
BUN
Sodium Chloride
Creatinine
Potassium Bicarbonate
Glucose
Example:
11
138 97
1.2
4.2 23
Figure 11-1 Written shorthand for
104 documenting laboratory test results.

Plan Sullivan tests to be 6662
done and (ifany
needed)
therapeutic
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The Plan section of the daily visit note outlines changes
Fig. #
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6662_C_F11_01.eps with a specialist as
Date
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When documenting daily rounds at facilities where
ture results that had not been available at the time of
EMRs are used, there is a temptation to speed up the
admission. If a new problem has been identified, such
process by copying and pasting entire notes or portions
as shortness of breath concerning for a pulmonary
of notes. The practice of duplicating information within
embolism, you should document the plan to address
the same patient record or moving it across multiple
this concern. This may include procedures or diagnostic

records creates potential risks to the integrity of the

patient each day. Is the patient getting adequate pain
medical record, which include:
relief? Has bowel function returned? Can the patient’s
activity level be advanced? Can the patient’s diet be
• Copying and pasting inaccurate or outdated advanced? Can any sutures, staples, tubes, or drains
information be removed? You should also determine whether any
• Redundant information in the EMR, which makes it postoperative complications have occurred. You can
difficult to identify the current information anticipate what complications are likely based on the
• Inability to identify the author or intent of the type of surgery that was done and then document
documentation enough information in the Subjective and Objective
• Inability to identify when the documentation was first portions of the note to convey that such complications
created have or have not occurred.
• Propagation of false information Postoperative complications that can develop after
• Internally inconsistent progress notes almost any type of surgery include fever, urinary re-
• Unnecessarily lengthy progress notes tention, fluid imbalance, and wound infection. More
The practice of copy/paste has become so widespread serious complications include hemorrhage, respiratory
that a special study was done by the ECRI Institute in depression, and pulmonary or fat embolism. Fever is the
2015 to explore its impact. In the report, authors dis- most common postoperative complication and usually
cuss three specific incidents where copying and pasting has one of five etiologies: respiratory, wound infection,
led to patient harm, even death. In one of the cases, a urinary tract infection, thromboembolic event, or drug
middle-aged man who was found to have atrial fibrilla- side effect or adverse reaction. You can remember these
tion and potential heart disease during an emergency etiologies by thinking of “wind, wound, water, walk, and
department visit was discharged to follow up with wonder drug” (the five Ws, explained in Table 11-1).
his primary care physician (PCP) for a stress test. The This should prompt you to ask the patient about any
PCP failed to diagnose cardiac disease and copied and symptoms that could indicate development of these
pasted the Assessment and Plan sections over 12 office complications, such as fever, cough, shortness of breath
visits during the next 2 years. The patient died from a or difficulty breathing, increased pain at the operative
heart attack, and the physician was successfully sued site, and swelling of the legs or calf pain. You would
(Samaritan, 2010). Aside from potential patient harm, document the answers as pertinent positives or negatives
EMR notes are being scrutinized by CMS and other in the Subjective portion of the note.
payers to determine if copy/paste portions of the note Examining the cardiovascular and respiratory systems
constitute fraud, which could result in not only denial is part of the objective evaluation of most postoperative
of payment but also civil and criminal penalties. Most patients. Additionally, you should inspect the surgical
institutions have policies regarding use of the copy/paste incision or operative site and describe its appearance
function, and several professional organizations have de- in the note. Document the presence of any drains and
veloped policy statements addressing this practice. The the amount and characteristic of any drainage. If the
message is clear: copy and paste with caution. 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
Surgical Admissions bowel sounds. Tailor the rest of the examination to the
Figure 11-2 illustrates the documentation of a daily type of surgery that was performed. Do not neglect to
progress note for a surgical patient. The note was created assess for and document any pertinent findings related
in an EMR and demonstrates important subjective to pre-existing or comorbid conditions the patient may
and objective information that should be assessed for have. A sample progress note for POD #1 for Mr. Jensen
all surgical patients. When documenting the daily is shown in Figure 11-3.
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 Daily Orders
helpful when trying to determine whether the patient
is progressing as expected after surgery because there is Any time there is a change in the plan of care for a hos-
a fairly well-established time frame for certain events, pitalized patient, you must write a corresponding order
such as when bowel function returns, when drains are to reflect that change. Remember that in Chapter 10
removed, and healing of a surgical incision. we said that an order stays in effect until another order
When rounding on postoperative patients, you can is written to modify or discontinue it. Once you have
ask certain questions to guide your evaluation of the assessed the patient and recorded the daily progress


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Figure 11-2 Progress note from an EMR for a surgical patient.

Table 11-1 The Five Ws of Postoperative Fever

When Fever Is
Category System Likely to Occur Potential Problems What to Assess
Wind Respiratory Within first 48 hr Hypoventilation, Respiratory rate and effort, breath
after surgery atelectasis, pneumonia sounds
Wound Integumentary Postoperative Wound infection, abscess Amount and character of drainage,
days 4 to 7 erythema, induration, increased
tenderness at operative site
Water Urinary Anytime Urinary tract infection Fever, chills, flank pain, urgency, dysuria;
(UTI), sepsis amount, color, and smell of urine
Walk Vascular Postoperative Deep vein thrombosis Calf tenderness, swelling, temperature
days 5 to 14 (DVT) of extremities
Wonder Multisystem Drug adverse reaction or All medications the patient has had
drug drug–drug interaction since surgery
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:
Figure 11-3 First postoperative day progress note for Mr. Jensen.
note, you should write orders that correspond to any Any time you make a change in the management of
changes addressed in the plan. You might want to the patient, you should evaluate the response to that
refer back to Figure 10-8 to review the postoperative change during the next visit. For instance, based on the
orders that are currently in effect for Mr. Jensen. Now, plan documented in the POD #1 note, you wrote an
look at the Plan portion of the SOAP note shown in order to remove the urinary catheter. The next time you
Figure 11-3. You will notice that you need to write an round on Mr. Jensen, you should assess his response
order to remove the urinary catheter and another to to removal of the catheter. Was he able to void after it
change Mr. Jensen’s activity level to allow for bathroom was removed? Did he experience any urinary retention?
privileges and for him to be out of bed at least three Then document the response in the progress note.
times a day. As with any entry in the medical chart, you Figure 11-3 shows POD #1 note for Mr. Jensen. Use
should indicate the date and time, write the necessary Application Exercise 11.1 as an opportunity to write
orders, and then add your signature and title. orders based
Author on the Plan portion
ISBN # of the note.
Author's review
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Write orders that reflect the changes needed for Mr. Jensen’s care.

1. Discontinue indwelling catheter.
2. OOB at least TID with bathroom privileges.
Next you will see the Subjective and Objective information to write the Assessment and Plan portions,
portions of the POD #2 note for Mr. Jensen. Use this and then write any orders necessary.

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.
(Continued )


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
Consult Note
Application Exercise 11.2, is shown in Example 11.1. As we discussed in Chapter 10, a hospitalist, usually
EXAMPLE 11.1 an internal medicine specialist, is the provider who
oversees the patient’s hospitalization. Depending on
A/P: what problems arise during the hospital stay, con-
1. S/P hemicolectomy, POD #2: progressing as sultation with specialists may be necessary. A patient
e xpected. Activity as tolerated. may have been admitted for diabetic ketoacidosis and
2. Return of bowel function: advance to clear liquid diet. while in the hospital developed cellulitis of the leg,
3. Wound healing without signs of infection: continue which would prompt consultation with an infectious
routine wound care. disease specialist. The same patient may experience new
4. Hyper tension, previously stable on medication: onset of atrial fibrillation, necessitating consultation
restar t Lotensin HCT 20/12.5 mg PO daily and with a cardiologist. Each specialist will document his
Mevacor 20 mg PO daily. 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
MEDICOLEGAL ALERT ! the consult. The history of present illness (HPI), past
medical history (PMH), and review of systems (ROS)
Problems might arise when an intervention that should
are usually limited to the most pertinent information
be done is omitted. An example is a patient who needs
for each specialty (Fig. 11-4). Refer to Figure 10-10,
to have regular treatments with a bronchodilator but the
the Admission H&P for C.H., which was authored
order is never written.The patient develops respiratory
by the hospitalist, Dr. Mason. As part of the plan of
difficulty because an intervention was warranted but not
care, Dr. Mason includes obtaining urology consul-
done.There might also be problems if an intervention is
tation. Figure 11-5 shows a urology consult note for
done longer than necessary. An example of this is when a
C.H. Also refer to Figure 10-11, the Admission H&P
patient has a urinary catheter that could be removed but
for G.M., noting where Dr. Brooks has indicated the
the order is not written.The catheter remains in place lon-
need for a cardiology consultation, which is shown in
ger than necessary and the patient develops a UTI. Always
Figure 11-6. Read and compare the two consult notes,
remember to assess on a daily basis what interventions
noting how the history, examination, assessment, and
are indicated and which ones may be discontinued.
plan are focused for each specialty.

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Figure 11-4 Sample consult note from an EMR. Sullivan 6662 (if needed)
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Copyright © (Width
Final Size 2019Xby F. A.
Depth Davis Company. All rights reserved.
in Picas) Date

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
Figure 11-5 Urology consult note for C.H.

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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
Cardiac Consultants
Figure 11-6 Cardiology consult note for G.M.

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Full Operative Report • Indication: reason for the procedure

• Surgeon
and Operative Note • Surgical assistants, if any
• Anesthesia: local, general, regional; name of
A full operative report, which provides a detailed narrative person administering anesthesia
of the surgical procedure, must be documented for every • Pre-operative diagnosis: presumptive diagnosis
patient undergoing surgery. The surgeon dictates this before surgery
report. A full operative report for Mr. Jensen is shown • Postoperative diagnosis: most likely diagnosis
in Figure 11-7. Because there could be a significant time based on surgical findings
lapse between the time the operative report is dictated and • Descriptions
the time it is transcribed and placed in the chart, often the • Specimens: what tissue was removed and what
provider will write a brief operative note. This is similar studies were done
to writing an admit note to summarize the admission • Estimated blood loss (EBL)
H&P and indicating that it has been done and dictated. • Drains: types of drains, if any, and where placed
The operative note (or “op note”) is written in the chart • Complications, if any (such as a nicked artery,
or completed in the EMR immediately after surgery, punctured bowel, or complications from
and it remains part of the medical record even after the anesthesia)
full transcribed operative report is placed in the chart. • Disposition
The operative note includes the following information:
• Date of procedure Review the full operative report for Mr. Jensen shown
• Name of procedure in Figure 11-7 and complete Application Exercise 11.3.
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.
Figure 11-7 Full operative report.

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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:
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 • Consent (if required, including risks and

benefits, potential complications, and name and
In addition to admission H&Ps, admit notes, daily relationship of person giving consent)
progress notes, and operative notes, other types of • Anesthesia (if applicable)
documents are frequently created during the course of • Details of the procedure
a patient’s hospital stay. Procedure notes are discussed • Findings (if relevant)
in this chapter; discharge summaries and discharge • Complications
orders are discussed in Chapter 12 as are documentation
related to patient elopement and a patient leaving the Suppose that, while he was in the hospital, Mr. Jensen
hospital against medical advice. fell and sustained a laceration to the scalp. You
are called to evaluate him and, after examination,
Procedure Note you determine that the laceration requires closure.
The purpose of the procedure note is to document After the laceration is repaired, you document the
why and how a procedure was done and the patient’s procedure. You could use the SOAP note format;
response to the procedure. The usual format includes however, it is more likely that you would write a pro-
the following elements: cedure note instead. Example 11.2 shows a procedure
• Name of the procedure note documenting the repair of Mr. Jensen’s scalp
• Indication for the procedure laceration.

EXAMPLE 11.2 document a biopsy done at a dermatology office, removal

of a toenail at a primary care clinic, or thoracentesis
xx/xx/xxxx Procedure Note
done in the emergency department. Figures 11-8 and
1845 Procedure: Laceration repair
11-9 show two different procedure notes.
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- MEDICOLEGAL ALERT !
ing; verbal consent for repair given by Mr. Jensen
Anesthesia: Local with 1% lidocaine with epinephrine The issues related to consent are complex. Consent is
Procedure: The area was prepped and draped in the not merely a form that needs to be completed; obtaining
usual sterile fashion. After administration of local the patient’s consent means obtaining the patient’s au-
anesthesia, the wound was explored; no foreign thorization for diagnosis and treatment. The person being
bodies or step-offs were palpated. The wound was asked to consent to a procedure must have the capacity
cleansed with Hibiclens and sterile water. The lac- to understand the rationale for the procedure, any alter-
eration was repaired with 3.0 nylon suture with a natives to the procedure, and risks and benefits of the
total of four interrupted sutures. Good approxima- procedure. It is the responsibility of the provider who will
tion and hemostasis was achieved. Topical antibi- perform the procedure to provide enough information
otic ointment was applied. to the patient so that he or she can make an informed
Complications: None decision. Courts have consistently held that it is not the
Signature, title 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
You may use the procedure note in many settings
who may give consent if the patient is unable to consent.
for a variety of procedures. You could use the note to
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
Figure 11-8 Procedure note for incision and drainage.
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
Figure 11-9 Procedure note for skin biopsy.


Summary focus of treatment and documentation. Well-written

documentation from admission through discharge
The average length of hospital stay is 4.8 days. During a should provide a meaningful, unambiguous narrative
hospitalization, the attending physician must assess his of all treatment provided to the patient as well as his or
or her patients on a daily basis, document the patients’ her response to treatment. Providers must safeguard the
response to therapy, and determine what changes, if integrity of the patient’s medical record and, therefore,
any, are needed for each patient’s plan of care. Orders should exercise extreme caution if copying and pasting
written by treating providers direct the health-care any portion of the record. Completion of the worksheets
team in all aspects of care, from obtaining vital signs to that follow will help reinforce the content provided in
administering medication. In addition to the attending this chapter. And be sure to review Appendix A, the
physician, various specialists and ancillary personnel may Document Library, for full case examples of patient
interact with patients. Each will have his or her own documentation.

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.

5. List at least three risks associated with copying and pasting notes.
6. List the five Ws that could be sources of postoperative fever.

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: ��

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
Figure 11-10 Operative report for K.S.

OK Correx
278 Copyright © 2019 by6662_C_F11_10.eps
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Date
Artist Date
04/05/18
Check if revision X
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B/W 4/C 2/C X PMS

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?

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.

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

Chapter 12
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.
may benefit from more coordinated care management,

Introduction intensive assessment, and additional services after
hospital discharge.
Events that occur during a hospitalization may have
The hospitalist and others involved in the patient’s
significant impact on a patient’s health. The patient may
care should provide clear instructions about specific
be dealing with new diagnoses and ongoing conditions,
care needed after discharge, symptoms that should be
and he or she may feel anxious about going home.
reported to providers, and when follow-up appointments
The process of transitioning from hospital-based care
are needed. In Chapter 10, we saw that specific orders
to community-based care presents several challenges.
are written when a patient is admitted to the hospital.
Hospital providers must consider many factors that
Likewise, specific orders are written at the time of dis-
contribute to patients’ readiness for discharge. Even
charge. In addition to the discharge orders, a discharge
though leaving the hospital, patients may sometimes
summary must be completed and provided to members
require some form of ongoing care, and in such instances,
of the health-care team that will be involved in the
the hospital staff must be sure that patients have the
patient’s care outside of the hospital environment. We
support they need with a specific goal of preventing
again follow Mr. Jensen to see how discharge orders
hospital re-admission within 30 days. Hospitals with
and discharge summaries are written.
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- Discharge Orders
clinical, that increase a patient’s risk of re-admission.
A summary of what is included in discharge orders is
Clinical factors were high-risk medications, including
listed here, and a discussion of each element is pre-
anticoagulants, steroids, and narcotics; and comorbid-
sented next.
ities, including congestive heart failure, renal disease,
diabetes, cancer, anemia, and weight loss. Nonclinical • Disposition (where the patient will go after
risk factors include lack of adequate support (social, discharge from the hospital)
familial, financial); premature discharge; nonadherence • Activity with specific instructions
with follow-up procedures or instructions; substance • Diet
abuse; homelessness; barriers to learning; and delay in • Medication reconciliation, including prehospital
seeking medical treatment at the first sign of recurring medications that should be resumed or stopped as
symptoms. Patients who have any of these risk factors well as any new medications
285

• Follow-up instructions (who and when) or could not eat or drink for other reasons, the diet is
• Notification instructions (signs or symptoms that usually advanced to the prehospital diet over several
could signal complications) days as the patient’s condition improves and the pa-
tient meets certain criteria. Mr. Jensen has a history of
Disposition hypertension and dyslipidemia so the diet instructions
The first part of the discharge order usually indicates should reflect the need for a special diet. A reasonable
the disposition, or where the patient will go when plan for Mr. Jensen is a low-fat, low-cholesterol heart-
discharged. The patient may go home or may be trans- healthy diet.
ferred to another facility, such as an extended care or
rehabilitation facility. If the patient is discharged home Medication Reconciliation
but will need home health services, the arrangements Medication reconciliation, or medication review, is
for those services must be confirmed before the patient the process of verifying patient medication lists at a
leaves the hospital so that there is no gap in care. In point of care transition, such as hospital admission
the case of Mr. Jensen, he will return home because he and discharge, to identify which medications have
does not require specialized care. been added, discontinued, or changed relative to
pre-admission medication lists. (Medication recon-
Activity Level ciliation during the admission process is discussed in
You should specify in the discharge orders the level Chapter 10.) Performing medication reconciliation is
of activity that the patient is allowed. Mr. Jensen has a critical element of a successful discharge transition.
an abdominal incision so he should not do any heavy It also provides an opportunity for you to ensure
lifting or straining in order to prevent dehiscence of that patients understand what medications they are
the wound. An order that says, avoid heavy lifting is taking, how to take them, and why they are taking
vague, and the patient is usually not in the position to them. Once an accurate discharge medication list is
determine how much weight is too heavy. It is best to generated (Fig. 12-1), you need to communicate this
give a specific weight limit. A low weight is advised information clearly and effectively to the patient and/
for Mr. Jensen; 10 pounds is the maximum he should or caregivers, and you should provide written instruc-
lift, although some surgeons might limit the weight tions to the patient with complete dosing instructions
to 5 pounds. Often patients who have had surgery are for each medication.
instructed not to drive for a certain amount of time Just as you had to write orders for medications while
after surgery. For patients who have had abdominal the patient was hospitalized, your discharge orders
surgery, the minimum restriction is usually 1 to 2 weeks; should indicate what medications the patient will
some procedures, especially orthopedic, might require continue after discharge. First, consider what medi-
a restriction period that is even longer. Patients should cations the patient was taking before hospitalization.
specifically be told not to drive or operate machinery In Mr. Jensen’s case, he was taking Lotensin HCT
if they are taking prescription pain medication; doing 20/12.5 and Mevacor. Because these medications
so is considered driving under the influence. If there treat chronic conditions that he still has, they should
are activity restrictions that affect a patient’s ability be continued. You should write an order to continue
to return to the regular work duties, employers may usual dosages of these medications. Next, consider
require documentation of the specific limitations; that what medications might be indicated related to the
is, cannot stand for more than 2 hours at a time, no reason for the hospitalization. Mr. Jensen had major
lifting greater than 10 pounds for 4 weeks, cannot sit abdominal surgery and will need pain medication after
for more than 2 hours at a time, and so on. discharge. Usually, the same oral analgesic that was
Mr. Jensen has a surgical incision so activity orders given in the hospital will be continued at home because
should include care of the wound or specific instructions its efficacy has been established and the patient has
related to the wound. The wound can get wet but should been tolerating it without any problems. You should
not be immersed in water. Therefore, an order should write a prescription for any medications the patient
specify that he may shower but should not take a tub has not taken previously so you will need to write a
bath, sit in a hot tub, or go swimming. Mr. Jensen will prescription for an analgesic (prescription writing is
need to continue wound care at home. Instead of writing discussed in Chapter 9). Finally, consider whether
out the specific wound care orders, you may write an other medications, prescription or over-the-counter,
order for the nursing staff to instruct on wound care. are needed. Some medications that may be needed
include stool softeners, sleep aids, and nonsteroidal
Diet anti-inflammatory medications for mild to moderate
Consider what type of diet the patient should have at pain. Be sure to write a prescription for any medications
home. If a patient had surgery during the hospitalization that are not available over the counter.

Chapter 12 Discharging Patients from the Hospital | 287
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.
Follow-Up Care and Notification 100.5˚F, redness or increased pain at incision site, cough,
Instructions difficulty breathing, or pain or swelling of the leg.
Also Mr. Jensen would follow up with his primary
Follow-up care should also be part of the discharge
care provider (PCP), Dr. Vernon Scott, because he has
orders. Specify by whom and when the patient will
chronic conditions
Author that needISBN continued
# monitoring
Author's review and
be seen. Mr. Jensen will see the surgeon, Dr. Sanders,
management that
Sullivan
typically the surgeon
6662
would not
(if needed)
provide.
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2 weeks from the time of discharge for wound evaluation, Fig. # Document name
The timeF12_01
frame of follow-up will vary depending onDate the
removal of staples or sutures, and a routine postoperative 6662_C_F12_01.eps
patient’sArtist
overall health status Date and whether the chronic
Initials
checkup. Follow-up care should also include special in- 04/10/18
conditions are stable or unstable.
AB/CO Because
X Editor's Mr. Jensen’s
review
structions for the patient, such as notifying Dr. Sanders Check if revision
hypertension
B / W X and4/Cdyslipidemia
2nd are stable, he should
color OK Correx
if any symptoms of complications occur. You should 2/C PMS
see Dr. Scott in 1 to 2 weeks. Example 12.1 showsDate
Final Size (Width X Depth in Picas) the
specify which symptoms should be reported because
complete41p0 set of discharge orders for Mr. Jensen.
x 24p1 Initials
the patient may not realize the importance of certain
symptoms. Consider what postoperative complications
EXAMPLE 12.1
might occur and what symptoms would be associated
with those complications. Any patient who has had 1. Discharge to home.
major abdominal surgery is at risk for developing 2. No lifting greater than 10 pounds; no driving,
wound infection, pneumonia, deep vein thrombosis, e xercising, or strenuous activity until released by
or pulmonary embolus. Symptoms that correspond Dr. Sanders.
to these conditions include fever, redness or increased 3. May shower but no tub bath, hot tub use, or
pain at the incision site, difficulty breathing, and pain in swimming until released by Dr. Sanders.
the leg. “Fever” is somewhat subjective (just like “heavy 4. Instruct on routine wound care.
lifting” discussed earlier), so it is best to state a specific 5. Low-fat, low-cholesterol hear t-healthy diet.
temperature that would be of concern. A typical order 6. Continue Lotensin HCT 20/12.5 and Mevacor
would read, notify Dr. Sanders of temperature greater than at home.

7. Ibuprofen 800 mg PO q6h with food PRN mild for participating in federal reimbursement programs,
to moderate pain. for example, require that hospital records be completed
8. Oxycodone 10 mg 1 or 2 tablets PO q4h PRN within 30 days following the patient’s discharge. Hospitals
moderate to severe pain. may have their own requirement for when discharge
9. Colace 100 mg PO twice daily for 1 week to summaries must be done, and the person responsible
p revent constipation. for completing the discharge summary may be placed
10. Follow-up with Dr. Sanders in 2 weeks. on suspension if it is not done within the required time
11. Notify Dr. Sanders if temperature greater than frame. Usually the discharge summary is dictated, and
100.5˚F, redness or increased pain at incision site, transcribed copies are placed in the chart and sent to
cough, difficulty breathing, or pain or swelling in the admitting physician and other consulting provid-
the legs. ers as indicated. In some facilities, voice-recognition
12. Follow-up with Dr. Scott in 1 month for software programs may be used instead of dictation
routine care. 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
MEDICOLEGAL ALERT ! vary from institution to institution. The headings shown
below (and in Table 12-1) indicate what information
Failure to provide adequate follow-up instructions is should be part of the discharge summary.
one of the leading causes of litigation against health-care
providers in both inpatient and outpatient settings. It is • Date of admission
your responsibility to anticipate what complications the • Date of discharge
patient might develop and to educate the patient on the • Admitting diagnosis (or diagnoses)
signs and symptoms that could indicate such a complica- • Discharge diagnosis (or diagnoses)
tion. Patients cannot be expected to know what signs or • Attending physician
symptoms need to be reported. Follow-up instructions • Primary provider and consulting physician(s)
and the documentation of such instructions should be (if any)
as specific as possible. It is a good idea to verify that the • Procedures (if any)
patient has understood the follow-up instructions by • Brief history, pertinent physical examination find-
asking the patient to repeat back to you what he or she ings, and pertinent laboratory values (at time of
has heard about the follow-up instructions. Then docu- admission)
ment that the patient appeared to understand follow-up • Hospital course
instructions. It is also recommended that you provide • Condition at discharge
follow-up instructions in writing as well because the • Disposition
patient is not likely to remember everything that was • Discharge medications
said verbally. Include family members or others who may • Discharge instructions and follow-up instructions
be caring for the patient after discharge and document
who, besides the patient, received follow-up instructions. Dates of Admission and Discharge
If the patient is non-English speaking or has low level En- The dates of admission and discharge are easily deter-
glish proficiency, you should provide the written instruc- mined from the medical record.
tions in the patient’s preferred language.
Admitting and Discharge Diagnosis
(or Diagnoses)
Discharge Summary The admitting diagnosis can be found in the initial
admitting orders. The discharge diagnosis might be
The discharge summary is a synopsis of the patient’s the same as or different from the admitting diagnosis
entire hospitalization and is required for any hospital or might include several diagnoses. If you have not
stay longer than 24 hours. Often, members of the been following the patient on a regular basis, you may
health-care team, insurance carriers or other third-party have to read through the entire chart to identify all
payers, and quality assurance personnel request a copy the diagnoses. The discharge diagnosis should be the
of the discharge summary. The discharge summary primary reason for hospitalization; secondary diagnoses
must be completed before the hospital can submit for will be listed as well. For Mr. Jensen, adenocarcinoma
payment. For these reasons, you need to complete the of the colon is the discharge diagnosis with secondary
discharge summary in a timely manner. Regulations diagnoses of hypertension and dyslipidemia.

Table 12-1 Discharge Summary Contents and Brief Description

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 List names of those who provided consultations for this patient during the course
(if any) of hospitalization; if none, omit heading
Procedures (if any) If none, omit heading
Brief history, pertinent Events leading up to hospitalization, pertinent PMH, pertinent examination findings
examination findings and at time of admission, and pertinent laboratory values at time of admission
pertinent laboratory values
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 Include activity level, signs or symptoms of potential complications that the patient
follow-up 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
Attending Physician, Primary Provider, as a coronary arteriogram, a bronchoscopy, or wound

and Consulting Physician debridement. Minor procedures, such as insertion or
removal of a drain, are rarely included here.
The attending (or admitting) physician is the provider
primarily responsible for the patient during the entire
hospitalization. For a surgical admission, this is almost
Brief History, Pertinent Physical
always the surgeon. For a medical admission, this is Examination Findings, and Pertinent
typically the hospitalist. When hospitalists manage the Laboratory Values
patient, a copy of the discharge summary should always The brief history, pertinent physical examination findings,
be sent to the PCP to be kept with the patient’s records. and laboratory data are in the admission history and
This helps provide continuity of care and documents physical examination (H&P). Do not repeat everything
important details of the hospitalization that could already documented in these sections; instead, highlight
affect management of the patient after hospitalization. any pertinent findings that relate to the reason for
Any consulting physicians involved in the care of the the current hospitalization. The goal is to summarize
patient should be listed and should receive a copy of the information already in the medical record. For the
the discharge summary. It is recommended to include history, include enough information to indicate why
the name of consulting physicians and their specialty. hospitalization was necessary. In the case of Mr. Jensen,
This is particularly helpful when a patient has had a it is appropriate to mention his initial presentation of
complicated hospital course and was seen by multiple fatigue, the finding of blood in the stool, and the subse-
specialists. This helps provide continuity of care and quent diagnosis of adenocarcinoma. Pertinent findings
ensures that the PCP has a record of the specialists from the past medical history, current medications,
who have already seen the patient in case consultation and allergies are customarily included in this section
is needed in the future. of the discharge summary. There were no significant
findings from Mr. Jensen’s physical examination; thus,
Procedures it is permissible to state The physical exam findings
You should list any surgical procedures the patient were unremarkable. You should summarize pertinent
had during the hospitalization. Some diagnostic or baseline laboratory data. For a surgical admission, the
therapeutic procedures should be listed as well, such pre-operative hemoglobin and hematocrit (H&H) is

usually included (even if normal) as well as any ab- summary. It takes practice in the art and science of
normal findings from chemistry studies, such as the medicine and documentation to develop a concise and
carcinoembryonic antigen (CEA) of 17 for Mr. Jensen. informative hospital course narrative without being
His dyslipidemia is a chronic problem so you could too verbose or leaving out important details. Think of
document the total cholesterol and triglyceride values; this section as the story of the course of events of the
however, because this chronic condition is not likely to patient’s hospitalization. Summarize the daily progress
have an effect on this hospitalization, it is not necessary of the patient and the patient’s response to treatment
to include these values. You would also document in as documented in the daily progress notes. A great
the discharge summary any abnormality that needed deal of detail usually is not needed but include enough
correction before surgery or that would significantly information to avoid ambiguity or an incomplete record
affect the patient’s overall hospitalization. of the patient’s hospital stay. Some providers summa-
rize the events of each hospital day; this format works
Hospital Course well when the stay is brief and the patient’s recovery is
The hospital course is the most important part of the uneventful. This approach is not recommended if the
discharge summary. It also can be the most difficult hospitalization is longer than 5 days or if the patient
part to document. Up to this point, you have taken the has multiple problems. In those instances, you might
information in the discharge summary directly from construct the narrative to summarize the details of
other sections of the medical record. The hospital course each problem and the patient’s response to treatment
narrative is a summary of information that is already for each problem. Some hospitals may require the use
recorded in daily progress notes, consultants’ notes, or of a specific format. To gain experience summarizing
procedure notes, but the challenge is learning what to details of a patient’s hospital stay, complete Application
include and what can be omitted from the discharge 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?
• 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.

Condition at Discharge their addiction. It seems likely that leaving AMA puts
Your discharge summary should also include a specific patients at increased risk for adverse health outcomes.
assessment of the patient’s condition that should in- This concern is supported by several studies that found
dicate why the patient is ready for discharge. Avoid that patients who leave AMA have significantly higher
one-word descriptions such as stable or improved. In re-admission rates than other patients. Glasgow and
the case of Mr. Jensen, you could state, Mr. Jensen is colleagues (2010) conducted a study of general medical
tolerating a regular diet, has adequate pain relief from oral patients who left AMA. The study sample included
analgesics, and he is able to ambulate without assistance 1,930,947 medical admissions to 129 hospitals from
and to perform activities of daily living. His postoperative 2004 to 2008; 32,819 patients (1.70%) were discharged
recovery is progressing as expected without complications. AMA. These patients had a higher 30-day re-admission
rate and higher 30-day mortality rate.
Disposition, Discharge Medications, When a patient states a desire to leave the hospital
Discharge Instructions, and Follow-Up before being ready for discharge, it is your responsibility
Instructions as the admitting (or attending) physician to determine
if the patient has capacity to make informed decisions.
The disposition indicates where the patient goes when The law dictates that a patient who has capacity has
leaving the hospital. If the patient is being transferred the right to refuse medical care, and treatment without
to another facility, you should document the reason consent may be considered battery. When a patient signs
for transfer. The discharge medications, instructions, out AMA, he or she is exercising this right to refuse
and follow-up were discussed in the previous section care. However, if a patient is not capable of making an
on writing discharge orders. List the medications and informed decision, then you cannot ethically or legally
document any specific instructions in this part of the allow a discharge that may imperil the patient’s life or
discharge summary. health. A patient’s right to refuse care can be exercised
A discharge summary for Mr. Jensen is shown in only if a patient has decision-making capacity. An
Figure 12-2. After reading it, try to answer these ques- assessment of decision-making capacity focuses on
tions: When did bowel sounds return? Did Mr. Jensen a patient’s ability to understand and communicate a
have effective pain relief from the oral analgesic? Did rational decision. This determination centers around
he experience any postoperative complications? What whether a patient can manipulate information regard-
medications will Mr. Jensen take at home? When will ing a specific task or procedure. It does not require
Mr. Jensen see Dr. Sanders? A well-written discharge that a patient be free of mental illness or delusions.
summary will answer most questions a reader might To have capacity the patient must have the ability to
have about the events of the hospitalization. express a choice and communicate that choice, the
ability to understand relevant information, the ability
to appreciate the significance of the information and
Patient Leaving Before its consequences, and the ability to manipulate infor-
Discharge mation. Capacity is not the same thing as competence.
Competence is a legal determination made by a court;
Two events requiring careful documentation are patients capacity can be evaluated by the hospitalist or attending
leaving the hospital against medical advice (AMA) physician. If you are not sure if a patient has capacity,
and elopement. then you may consult a psychiatrist to evaluate the
patient and determine capacity. If the patient’s capacity
AMA is confirmed, then the patient may leave. Even if the
If a patient is advised to remain in the hospital and patient is leaving AMA, you should make every effort
he or she still chooses to leave, the patient is said to to provide adequate discharge instructions and arrange
be leaving AMA. Patients leave AMA for a variety of for follow-up care. Remember to document the patient’s
reasons. When asked, they most commonly cite family decision to leave AMA in the medical record. Typically,
problems or emergencies; personal or financial obliga- the patient is asked to sign a form indicating that he or
tions; feeling bored, fed up, or well enough to leave; she has decided to leave AMA. An example of such a
or dissatisfaction with their treatment. Because most form is shown in Figure 12-3. If the patient is deemed
hospitals are smoke-free facilities, patients often leave to lack capacity, then you should keep him or her in
simply because they want to smoke. If this is the case, the hospital for further treatment, even if involuntary
the patient may be offered nicotine-replacement ther- admission is necessary.
apy and, if needed, anti-anxiety medication. Although Your documentation should include the name and
many patients who leave AMA have substance abuse relationship to the patient (if applicable) of any witnesses
problems, few of them attribute their decision to leave to to the conversation about the patient’s possible discharge.

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.
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 D51/2 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)
Author ISBN #
Author's review
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Artist Date
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AB Editor's review
Check if revision
2nd color OK Correx
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Initials
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.
Figure 12-2 Discharge summary for Mr. Jensen.
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: _________________________________
OK Correx
_________________________________________________________________________________________________________
F12_02_p2 6662_C_F12_02_p2.eps Date
Signature of legally authorized representative: _____________________________________________________________________
Artist Date
Initials
03/06/18
AB Editor's review
Check if revision
Witness: __________________________________________________________________________________________________
2nd color OK Correx
B/W X 4/C 2/C PMS
Relation to Patient: __________________________________________________________________________________________
Attending Physician Signature: _________________________________________________________________________________
Figure 12-3 Sample AMA form.
Use direct quotes of the patient’s statements to explain of him remaining in the hospital, primarily, continued
why the patient wants to leave. Do not document your investigation into the etiology of the chest pain he is
own interpretation of why the patient is leaving or include experiencing and pain relief. The patient has capacity
any judgmental or derogatory remarks about the patient. and understands the risks of leaving, including serious
Make every effort to arrange follow-up care for the patient. cardiac disease, permanent disability, and sudden cardiac
Document the discharge instructions and follow-up care death. Mr. Sanford had an oppor tunity to ask questions
just as you would for any other patient. Example 12.2 shows about his condition, and I answered them to the best
one way to document a patient’s decision to leave AMA. of my ability. He has been informed that he may return
for care at any time. A follow-up appointment with his
EXAMPLE 12.2 PCP has been scheduled for 2 days from now.
Signature of attending physician
xx/xx/xxxx, 1548. I was informed by Karen Macayo, RN,
nurse manager of telemetr y 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 Elopement
and leave my kids alone. My sister was taking care of Elopement occurs when a patient leaves the hospital
them, but she has to leave.” We discussed the benefits without being discharged and without the patient

informing staff of the desire to leave. Eloping patients confirmed that he was not there. Nursing staff stated
are often at risk for serious harm, and there are many that Mr. Sanford had not indicated to them that he
cases in which patient elopement has resulted in was planning to leave. Several overhead pages asking
death. Because patients do not inform hospital staff Mr. Sanford to return to his room were made without
of their intent to leave, there is no chance to discuss success. Security was notified, and they checked the
the risks of leaving and benefits of remaining in the hospital grounds. Mr. Sanford was not found and is
hospital for treatment. Elopement is different from presumed to have eloped.
wandering, which is used to describe when a patient Signature of attending physician
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 Summary
and time that you were informed of the elopement as
well as who notified you. The documentation should As a health-care provider, you should be aware of clinical
contain only facts and not speculation on why the and nonclinical factors that increase a patient’s risk for
patient eloped. A discharge summary is still required. re-admission, and you should weigh all these factors
In the disposition part of the discharge summary, state carefully when deciding that a patient is ready for dis-
that the patient eloped. An elopement prevents the charge. Once the patient is deemed ready for discharge,
patient from receiving specific discharge instructions specific orders are required. In addition to the Admission
and follow-up care information, and it is customary History and Physical, the Discharge Summary is one
to document that you were unable to provide this of the most important documents that will be gener-
information to the patient. ated during a patient’s hospitalization. This summary
Suppose that Mr. Sanford, the patient mentioned in should communicate important events of the patient’s
Example 12.2, had eloped rather than telling the staff hospital stay, including admitting problem, response to
that he was leaving AMA. Once the staff discovered treatment, and development of any new problems as well
the elopement and informed the physician, this was as the management of those problems. The medication
documented in the patient’s medical record as shown reconciliation done at the time of discharge is extremely
in Example 12.3. important and should ensure that patients know exactly
which of their prehospital medications to continue and
EXAMPLE 12.3 which, if any, should be discontinued. The medication
reconciliation also should detail any new medications
xx/xx/xxxx, 1948. I received a call from Karen M acayo, prescribed, why prescribed, and how long the medication
head nurse of telemetr y 5B unit, regarding Mr. San- should be taken. At the time of discharge, you should
ford. The nur se who was assigned to care for him provide the patient with specific information related
was making rounds when she first came on shift and to care at home, follow-up appointments, and diet and
noticed that Mr. Sanford was not in his room. His IV activity. Also, you should educate patients about any
had been disconnected, and the tubing was lying on symptoms that they should report to you or another
the bed. The IV catheter was still attached, and a small health-care provider. Provide written discharge instruc-
pool of blood was noted on the bedding. The oxygen tions to the patient or caregiver, in the patient’s preferred
tubing was found on the bedside table. A hospital language, so that the patient can review the information
gown was found on the bed. The nurse checked the after discharge. To reinforce the content of this chapter,
imaging schedule to be sure that the patient was not please complete the worksheets that follow. And be sure
in that depar tment; no imaging studies had been or- to review A ppendix A, the Document Library, for full
dered for Mr. Sanford, and a call to the depar tment case examples of patient documentation.

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.

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.

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.

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.

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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Artist Date
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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?

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 p
atterns. 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 r estored 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.

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.

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.

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.

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.

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

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)

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 �� CEA ��
H&H �� H&P ��
PCP ��

Appendix A
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.
309
13_Sullivan_AppA.indd 309 7/6/18 1:16 PM

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 d
ocument
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.

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 c ongestion; 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

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
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.

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 u
rgent 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
CONSULTATION REPORT:
Service: Gastroenterology
Requesting Physician: Daniel Krackov, MD
Reason for Consultation: Nausea, vomiting, and diarrhea

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

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.

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 e mesis; other-
wise negative.
Musculoskeletal: + Right leg pain, back pain; otherwise negative.
Remaining systems reviewed and are negative.

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
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.

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.

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

Performed by: Adam Olsen, DO
Service: Cardiology
Reason for Consultation: Elevated cardiac enzymes

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.

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.

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.

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
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. N ormal 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.

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.

1. Mild cardiac enzyme elevation: Suspect possibly secondary to volume depletion and mild heart strain. H
owever,
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

Performed by: Marjan Caronni, MD
Service: Neurology
Reason for Consultation: Lower extremity weakness

318 | Appendix A

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.

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.

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

Appendix A | 319
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, g lucose
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

Performed by: Shannon Dalton, PA-C for Dr. Troy Copeland
Service: Orthopedics
Reason for Consultation: Back pain, neck pain, leg pain

320 | Appendix A

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.

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.

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
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.

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

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.

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)
DATE THE PATIENT/RESPONSIBLE PARTY WAS FIRST ASKED ABOUT PREFERENCES RE-
GARDING LIFE-SUSTAINING TREATMENTS OTHER THAN CPR:
6/5/20XX

Appendix A | 323
WAS THE PATIENT/RESPONSIBLE PARTY ASKED ABOUT PREFERENCE REGARDING HOS-

PITALIZATION? (SELECT THE MOST ACCURATE RESPONSE)
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

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

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)
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

326 | Appendix A
LABS
ARE LABS TO BE PERFORMED THIS VISIT?
NO
FALLS
HAS THE PATIENT HAD A RECENT FALL?
NO
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

Appendix A | 327
Patient: R.C.
The next document is a palliative care consult for an inpatient who has relapsing lymphoma.

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

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

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

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
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.

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.

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

332 | Appendix A
Patient: S.L.
The next document is a psychiatric consult note on a hospitalized patient who has acute anxiety.

Appendix A | 333
Patient: S.L.
Performed by: AnaMaria Ricardo, APRN
Encounter Info: S.L., MRN 45217, Inpatient Medical
Service: Psychiatry
Requesting Physician: Dr. Reddy
Reason for Consultation: Anxiety

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

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

Appendix A | 335
Patient: M.B.
The next set of documents is the prenatal record for patient M.B.

336 | Appendix A
Patient: M.B.
Obstetrical Record
Madison Palmer, MMS, PA-C
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
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
Lungs: CTA bilaterally
Abdomen: Soft, nontender, bowel sounds
normoactive
Appearance: NAD
Thyroid: No nodules
Breasts: Normal to inspection and palpation Back: No CVA tenderness
Heart: RRR, no m/r/g Date of conception: Unknown
Extremities: No edema or varicosities Preliminary Estimated Date of Confinement:
Vulva: No masses or lesions 12/01/20XX
Vagina: No abnormal discharge
Cervix: Long, thick, closed U/S Estimate of EDC: 12/18/20XX
Uterus: Mobile, nontender U/S Estimate of Gestational Age: 7w4d
Adnexa: Nontender, no masses Date Performed: 05/05/20XX
Determination of Gestational Age Clinical EDC: 12/18/20XX
Last Menstrual Period: 2/24/20XX * The clinical EDC is the clinician’s best estimate of the due date
Cycle Length: q28 and regular and is the date used for clinical management.

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.
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.
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.
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.
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.
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.
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.

338 | Appendix A
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.
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.
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.
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.
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).
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).
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).

Appendix A | 339
Laboratory Studies
Basic Prenatal Panel Late Pregnancy Panel
Date: 4/20/20XX Date: 9/25/20XX
HGB: 11.8 Glucose Screen: 80
HCT: 36.0 HGB: 11.7
Antibody Screen: Negative HCT: 37.1
MCV: 90 MVC: 97
Platelets: 394 Platelets: 250
RPR/VDRL: Nonreactive Antibody Screen: Negative
Urine Culture: No growth RPR/VDRL: Nonreactive
HBSAg: Negative GBS: Negative
HIV Testing: Negative
Rubella Screen: Immune Optional Lab Studies
Chlamydia: Negative CF Screen
Gonorrhea: Negative Other Carrier Screen
Pap Smear: Negative cytology Varicella Immunity
Drug Screen
Aneuploidy Screening Early Glucose
Date: 05/05/20XX 3-hr GTT F_ 1 hr_ 2 hr_ 3 hr
Declined
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
11/29/20XX O47.9 Braxton Hicks contractions
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

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

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.

342 | Appendix A
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:
Head
Weight Length Circumference Temp Pulse Respirations
7 lb 2 oz 19.5 in. 13.5 in. 98.6 152 48
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

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

344 | Appendix A
One-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 1 month
Current Medications: Vitamin D 400 units daily
Allergies: NKDA
Vital Signs:
Weight Length Head Temp Pulse Respirations

Circumference
9 lb 3 oz 21.25 in. 14.5 in. 98.4 148 46
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:
9, passed newborn hearing screen, 1st Hep B administered in hospital, vitamin K and erythromycin eye ointment

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

˛ Appropriate Bonding/Responsive to Needs ˛ Infant Hands to Mouth/Self-Calming ˛ Postpartum Depression

Appendix A | 345
Gen: Well appearing, awake and alert
Normal external ears, TMs normal bilaterally. Normal external nose, septum midline, nares patent. Neck supple
Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4, umbilicus dry/healing, no drainage
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
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

346 | Appendix A
Two-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 2 months
Accompanied By: Mother
Allergies: NKDA
Vital Signs:

Circumference
11 lb 6 oz 22.75 in. 15.25 in. 98.5 142 42
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.
Birth History:

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
˛ 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

Appendix A | 347
˛ Appropriate Bonding/Responsive to Needs ˛ Infant Hands to Mouth/Self-Calming ˛ Enjoys Interacting

with Others ˛ Postpartum Depression
Abd: Soft, nondistended, no masses or organomegaly, bowel sounds positive ×4
MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight
Neuro: Normal suck, grasp, and Moro reflexes, alert
Assessment:
Plan:
concerns
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

348 | Appendix A
Four-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 4 months
Accompanied By: Father
Allergies: NKDA
Vital Signs:

Circumference
14 lb 3 oz 24.5 in. 16.25 in. 98.7 128 36
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.
Birth History:

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
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

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
Gen: Well appearing, awake and alert, smiling
Skin: Normal turgor without rash or lesions
MSK: Normal muscle tone, negative Barlow and Ortolani, spine straight, pushes up when prone
Neuro: Alert, cranial nerves intact
Assessment:
Plan:
concerns
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

350 | Appendix A
Six-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 6 months
Allergies: NKDA
Vital Signs:

Circumference
16 lb 2 oz 26.25 in. 16.75 in. 98.4 120 32
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.
Birth History:

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
˛ 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

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
with no mass or deformity, one bottom tooth starting to come in.
MSK: Normal muscle tone, spine straight, sits up with support
Assessment:
Plan:
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

352 | Appendix A
Nine-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 9 months
Allergies: NKDA
Vital Signs:

Circumference
18 lb 10 oz 27.5 in. 17.5 in. 97.9 118 30
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.
Birth History:
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
F luoride 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

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.)
˛ Appropriate Bonding/Responsive to Needs ˛ Self-Calming ˛ Growing Independence ˛ Shows Preference

for Certain People/Toys ˛ Cries When Primary Caregiver Leaves ˛ Postpartum Depression
Gen: Well appearing, awake and alert, smiling, babbling
with no mass or deformity, two bottom teeth and two top teeth.
MSK: Normal muscle tone spine straight, sits independently, crawling
Assessment:
Plan:
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.

354 | Appendix A
Pediatric Sick Visit

Name: R.B.
DOB: 12/20/20XX
Age: 10 months
Current Medications: Ibuprofen/Tylenol
Allergies: NKDA
Vital Signs:
Weight Length Temp Pulse Respirations

19 lb 2 oz 28.25 in. 99.2 132 34
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
Birth History:
Physical Exam:
Gen: Well appearing/well hydrated, sleeping initially in mother’s arms. Alert upon awakening, fussy during exam.

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

356 | Appendix A
Twelve-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 12 months
Allergies: NKDA
Vital Signs:

Circumference
20 lb 3 oz 29.5 in. 18.25 in. 98.0 112 28
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.
Birth History:
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
˛ Car/Car Seat Safety (Rear-Facing) ˛ Passive Smoke ˛ Safety at Home/Child-Proofing ˛ Sun Safety

Appendix A | 357
˛ Discipline/Praise ˛ Following Child’s Lead in Play ˛ Ignore Tantrums/Give Attention to Positive Behaviors

˛ Self-Calming ˛ Prefers Primary Caregiver over All Others ˛ Shy/Anxious with Strangers ˛ Tantrums
Gen: Well appearing, awake and alert, smiling/playful
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.
MSK: Normal muscle tone, spine straight, starting to walk
Assessment:
Pediatric well check/early childhood (1–4 years) – 99382
Plan:
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

358 | Appendix A
Fifteen-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 15 months
Allergies: NKDA
Vital Signs:

Circumference
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.
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
˛ 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

Appendix A | 359
˛ Communication/Language ˛ Social Interaction/Eye Contact/Comfort Others ˛ Begins to Have Definite

Preferences
Gen: Well appearing, alert, interactive
HEENT: Normocephalic, anterior fontanelle closed. PERRL, +red reflex bilaterally, no icterus, no drainage.
with no mass or deformity. Four bottom teeth and four top teeth with no obvious caries.
CV: Regular rate and rhythm, no murmur
MSK: Normal muscle tone, spine straight, walking/steady
Assessment:
Plan:
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.

360 | Appendix A
Eighteen-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 18 months
Allergies: NKDA
Vital Signs:

Circumference
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.
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
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

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

˛ Communication/Language ˛ Demonstrates Increasing Independence ˛ Defiant Behavior/Offer Child Choices

Appendix A | 361
Gen: Well appearing, alert, active
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.
MSK: Normal muscle tone, spine straight
Assessment:
Plan:
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.

362 | Appendix A
Twenty-Four-Month Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 24 months
Allergies: NKDA
Vital Signs:

Circumference
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.
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
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
˛ 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

Appendix A | 363

˛ Communication/Language ˛ Sense of Humor ˛ Demonstrates Increasing Independence ˛ Plays Alongside
Peers
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 including 2-year molars; no obvious caries.
MSK: Normal muscle tone, spine straight
Assessment:
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

364 | Appendix A
Five-Year Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 5 years
Allergies: NKDA
Vital Signs:
Weight Height BMI Blood Temp Pulse Respirations

Pressure
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.
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 N umbers
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
˛ 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

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)
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.
GU: Normal female external genitalia, Tanner stage I/I
MSK: Normal muscle tone and strength, spine straight, full ROM
Assessment:
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.

366 | Appendix A
Pediatric Sick Visit

Name: R.B.
DOB: 12/20/20XX
Age: 8 years
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
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
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
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

Appendix A | 367
MSK: Normal muscle tone, no joint swelling or stiffness
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

368 | Appendix A
Eleven-Year Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 11 years
Allergies: NKDA
Vital Signs:

Pressure
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.
No sudden, unexplained death or heart problems in the family before age 50
Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing 2× Daily/Flossing ˛ Dental Visits Every
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
˛ 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

Appendix A | 369
Gen: Well appearing, alert
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.
CV: Regular rate and rhythm, no murmur, 2+ peripheral pulses, cap refill less than 3 sec
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:
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).
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

370 | Appendix A
Sixteen-Year Well Check

Name: R.B.
DOB: 12/20/20XX
Age: 16 years
Allergies: NKDA
Vital Signs:

Pressure
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.
Health Risk Assessment: ˛ HEADSSS – no concerns
Oral Health: White Spots on Teeth: ®Yes ˛No ˛ Daily Brushing 2× Daily/Flossing ˛ Dental Visits Every
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

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
Gen: Well appearing, alert
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.
GU: Normal female external genitalia, Tanner stage V/V
MSK: Normal muscle tone and strength, spine straight, full ROM
Assessment:

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.
HEADSSS assessment completed with no concerns, no STI screening needed
Vaccines given today – Meningococcal – Vaccine education provided including possible side effects; VIS given

Appendix B
A Guide to Sexual History
Taking
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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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.
(Reprinted with permission from the California STD/HIV Prevention Training Center.)

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Appendix C
ISMP’s List of Error-Prone
Abbreviations, Symbols, and
Dose Designations
Institute for Safe Medication Practices
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations
TNational
he abbreviations, symbols, and dose designations found in
this table have been reported to ISMP through the ISMP
Medication Errors Reporting Program (ISMP MERP) as
nicating medical information. This includes internal communica-
tions, telephone/verbal prescriptions, computer-generated
labels, labels for drug storage bins, medication administration
being frequently misinterpreted and involved in harmful records, as well as pharmacy and prescriber computer order
medication errors. They should NEVER be used when commu- entry screens.
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 Use “discharge” and “discontinue”
“discharge”) has been misinterpreted as “discontinued” when
followed by a list of discharge medications
IJ Injection Mistaken as “IV” or “intrajugular” Use “injection”
IN Intranasal Mistaken as “IM” or “IV” Use “intranasal” or “NAS”
HS Half-strength Mistaken as bedtime Use “half-strength” or “bedtime”
hs At bedtime, hours of sleep Mistaken as half-strength
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 Use “daily”
medications administered in the eye
OJ Orange juice Mistaken as OD or OS (right or left eye); drugs meant to be diluted Use "orange juice"
in orange juice may be given in the eye
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 Use “daily”
the “q” is misunderstood as an “i”
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 Use “every other day”
poorly written
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” Use “subcut” or “subcutaneously”
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)
ss Sliding scale (insulin) or ½ Mistaken as “55” Spell out “sliding scale;” use “one-half” or
(apothecary) “½”
SSRI Sliding scale regular insulin Mistaken as selective-serotonin reuptake inhibitor Spell out “sliding scale (insulin)”
SSI Sliding scale insulin Mistaken as Strong Solution of Iodine (Lugol's)
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 Use “unit”
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)
UD As directed (“ut dictum”) Mistaken as unit dose (e.g., diltiazem 125 mg IV infusion “UD” misin- Use “as directed”
terpreted as meaning to give the entire infusion as a unit [bolus] dose)
Dose Designations Intended Meaning Misinterpretation Correction
and Other Information
Trailing zero after 1 mg Mistaken as 10 mg if the decimal point is not seen Do not use trailing zeros for doses
decimal point expressed in whole numbers
(e.g., 1.0 mg)**
“Naked” decimal point 0.5 mg Mistaken as 5 mg if the decimal point is not seen Use zero before a decimal point when the
(e.g., .5 mg)** dose is less than a whole unit
Abbreviations such as mg. mg The period is unnecessary and could be mistaken as the number 1 if Use mg, mL, etc. without a terminal
or mL. with a period written poorly period
following the abbreviation mL

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Institute for Safe Medication Practices
ISMP’s List of Error-Prone Abbreviations, Symbols, and Dose Designations (continued)
Dose Designations Intended Meaning Misinterpretation Correction

and Other Information
Drug name and dose run Inderal 40 mg Mistaken as Inderal 140 mg Place adequate space between the drug
together (especially name, dose, and unit of measure
problematic for drug Tegretol 300 mg Mistaken as Tegretol 1300 mg
names that end in “l”
such as Inderal40 mg;
Tegretol300 mg)
Numerical dose and unit 10 mg The “m” is sometimes mistaken as a zero or two zeros, risking a Place adequate space between the dose and
of measure run together 10- to 100-fold overdose unit of measure
(e.g., 10mg, 100mL) 100 mL
Large doses without 100,000 units 100000 has been mistaken as 10,000 or 1,000,000; 1000000 has Use commas for dosing units at or above
properly placed commas been mistaken as 100,000 1,000, or use words such as 100
(e.g., 100000 units; 1,000,000 units "thousand" or 1 "million" to improve
1000000 units) 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 Mistaken as tincture of opium Use complete drug name
deodorized tincture of opium
(Paregoric)
HCl hydrochloric acid or Mistaken as potassium chloride Use complete drug name unless expressed
hydrochloride (The “H” is misinterpreted as “K”) 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, Mistaken as TNKase (tenecteplase), or less often as another Use complete drug names
Activase (alteplase) tissue plasminogen activator, Retavase (retaplase)
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 Symbol for dram mistaken as “3” Use the metric system
Minim Symbol for minim mistaken as “mL”
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 Use “more than” or “less than”
symbol; “< 10” mistaken as “40”
/ (slash mark) Separates two doses or Mistaken as the number 1 (e.g., “25 units/10 units” misread as Use “per” rather than a slash mark to
indicates “per” “25 units and 110” units) 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 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 www.ismp.org
Web at www.ismp.org or by calling 1-800-FAIL-SAF(E).

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Index
A Allergic/immunologic system, review of, 29

Allergies
Tinetti Performance Oriented Mobility
Assessment tool, 162
Abbreviations admission orders, 228 Asthma, genetic tendency, 135
common prescription abbreviations, 203 comprehensive history and physical Asymmetrical tonic neck reflex, 108
dangerous abbreviations to avoid, 204 examination, 25–26 Attending physician, 289
Error-Prone Abbreviations, Symbols drug, 25 AUDIT (Alcohol Use Disorders
and Dose Designations, Appendix C in medication list, 176 Identification Test), 131, 132
errors, 195, 199, 201 perioperative orders, 230 Authorization, to disclose health
prescription writing, 203 Ambulatory medical care, 125 information, 11
Abdomen, examination of, 30 American Academy of Pediatrics (AAP), 94
Abdominal aortic aneurysm American College of Physicians (ACP),
screening, 138 186–187 B
Abducens nerve, 30 American Health Information Balance assessment, 162
Abortus, defined, 80 Management Association Bayley Scales of Infant and Toddler
Abuse, child, 102, 105 (AHIMA), 186 Development (Bayley-III), 99
Acoustic nerve, 30 American Medical Association, 5, 186 Beers criteria, 155
Activities of daily living, 156 American Recovery and Reinvestment Berg Balance Test, 162
Activity Act, 9 Billing information, 179
admission orders, 227 Americans with Disabilities Act, 219 Bishop score, 81–82
level, in discharge order, 286 Anorexia nervosa, 106 Blood product transfusions, 134
perioperative orders, 230 Anticipatory guidance, 100–102 BMI. See Body mass index (BMI)
AD CAVA DIMPLS mnemonic, Anti-emetics, 232 Body mass index (BMI)
225–226, 230 Apgar scoring, 86, 87 pediatric screenings, 94, 97–98
Admission orders, 223, 225–229 ASQ-3 (Ages and Stages risk-factor identification using,
Admit notes, 237 Questionnaires), 99 128–129
Admitting patient to hospital Assessments BRCA risk assessment and genetic
admission history and physical in admission history and physical counseling/testing, 137
examination, 218–221 examination, 220 Breast
admission orders, 223, 225–229 Assessment portion of SOAP notes, cancer screening, 137
overview of, 217 52–54, 257 examination of, 30
surgical history and physical balance and mobility, 162 genetic tendency for cancer, 135
examination, 221–223, 260, 261–263 BRCA risk assessment and genetic Bright Futures program, 93–94, 99
Adolescents, 102 counseling/testing, 137
Advance directives, 165 cardiopulmonary, 163
Adverse drug events cardiovascular disease, 138 C
electronic prescribing, 203 cognitive, 162 CAGE questionnaire, 130–131
hospitalized patients, 228, 234 comprehensive history and physical Cancer
medications, 201 examination, 32 breast, 135, 137
Against medical advice, patient leaving general, 48, 220 cervical, 137
hospital, 291, 293 geriatric risk factors, 153–162 colon, 137
Agency for Healthcare Research and medical admissions, 258 colorectal, 135
Quality (AHRQ), 137 Mini Nutritional Assessment—Short genetic tendency, 135
Ages and Stages Questionnaires Form (MNA-SF), 156, 159 oral, 134
(ASQ-3), 99 risk factor assessment through history ovarian, 135
Age-specific physical examinations, 106, taking, 153–160 screening mammography, 126
107–108 risk factor assessment through physical CAPTA (Child Abuse Prevention and
Alcohol consumption, 130–131 examination, 160–162 Treatment Act), 102
Alcoholism, 131 sexually transmitted infections, 137, 138 Cardiopulmonary assessment, pre-
Alcohol Use Disorders Identification Test in surgical history and physical operative evaluation of older
(AUDIT), 131, 132 examination, 223 adults, 163
17_Sullivan_Index.indd 387 7/6/18 1:36 PM

388 | Index
Cardiovascular system Comprehensive history and physical Denver Developmental Screening Test II
examination, 30 examination (DDST-II), 99
genetic tendency for disease, 135 assessments, 32 Department of Health and Human
review of, 28, 107 components of, 24 Services (HHS), 3, 5, 219
risk assessment for disease, 138 diagnostic studies, 32 Depression, 160, 161
Catheter care, 233 differential diagnosis, 32 Developmental screening, 98–99
CDC. See Centers for Disease Control and history. See History Diabetes mellitus
Prevention (CDC) laboratory studies, 32 genetic tendency, 135
CDSS (Clinical Decision Support physical examination, 29–31 screening, 137, 138
System), 205–206, 235 plan of care, 32 Type 2, 97–98
CDT (clock-drawing test), 162 problem list, 32 Diagnosis
Centers for Disease Control and sample, 32–35 admission orders, 227
Prevention (CDC) uses of, 23 perioperative orders, 230
body mass index, 94 Computer-based patient record, 8 Diagnostic studies
growth standards, 94 Computerized Physician Order Entry admission history and physical
medical records content for hospitalized (CPOE), 235–237 examination, 220
patients, 217 Condition admission orders, 229
older adult vaccinations, 162 admission orders, 227 comprehensive history and physical
oral health, 134 perioperative orders, 230 examination, 32
vaccinations, 100 Confidentiality, social media, 188 postoperative, 233–234
Centers for Medicare and Medicaid Consent, to disclose health information, pre-operative evaluation of older
Services (CMS) 11, 273 adults, 163
admission history and physical Consultation letter, 182, 184 surgical history and physical
examination, 218 Consultations, 54–55, 182 examination, 223
comprehensive history and physical Consulting provider, 182 Diagnostic tests
examination, 24 Consult note, 266–270 definitive diagnosis, 52–53
documentation guidelines, 3 Container information section, of prenatal care documentation, 82
electronic prescribing, 204 prescription, 201 screening, 126
EMR note review, 260 Contraceptive counseling and methods, 137 SOAP note documentation of results of,
prescription writing, 197 Controlled substances 50, 54
telemedicine, 186 closed distribution system, 196, 206 Diet
Cerebellum, 30 Controlled Substances Act (CSA), 196 discharge order, 286
Cervical cancer screening, 137 description of, 199 postoperative, 230, 232
Cervix score, 81–82 e-prescribing, 206 risk factor identification, 126, 128
Chief complaint, 24–25, 218, 221 prescription writing for, 201, 205 Diet order, 228, 230, 232
Child abuse, 102, 105 Coronary heart disease, 135 Differential diagnosis
Child Abuse Prevention and Treatment Counseling, health, 139 admission history and physical
Act (CAPTA), 102 Covered entities, 11 examination, 220
Childhood Maltreatment Interview CPOE (Computerized Physician Order comprehensive history and physical
Schedule—Short Form (CMIS-SF), Entry), 235–237 examination, 32
105–106 Cranial nerves, 30, 108 SOAP notes, 52, 53
Childhood obesity, 97 Cultural history, 27 surgical history and physical
Childhood Trauma Questionnaire, 105 Current Procedural Terminology codes examination, 223
Chronic condition, 7 description of, 5 Discharge orders, 285–288
Cigarette smoking, 129–130 evaluation and management services, 5–6 Discharge summary
Civil Rights Act of 1964, 219 fraud, 7 admitting and discharge diagnosis, 288
Clear liquid diet, 232 minutes used for medical discussion, 184 attending physician, primary provider,
Clinical Decision Support System and consulting physician, 289
(CDSS), 205–206, 235 condition at discharge, 291
Clock-drawing test (CDT), 162 D dates of admission and discharge, 288
CMS. See Centers for Medicare and Daily catheter care, 233 description of, 288, 289
Medicaid Services (CMS) Daily orders, 260, 264–266 disposition, 291
Coagulation studies, 179 Daily progress note follow-up instructions, 291
Code of Federal Regulations (CFR), content of, 257–260 history, 289–290
medical records content for description of, 257 hospital course in, 290
hospitalized patients (42 CFR medical admissions, 257–259 instructions, 291
482.24), 217 surgical admissions, 260, 261–263 laboratory values, 289–290
Codes. See Current Procedural Daily wound care, 233 medications, 291
Terminology codes DDST-II (Denver Developmental physical examination findings, 289–290
Cognitive assessment, 162 Screening Test II), 99 procedures, 289
Colon cancer screening, 137 DEA. See Drug Enforcement Agency sample, 292–293
Colorectal cancer, genetic, 135 (DEA) Disclosure, of health information, 11
Communication with patient, 183–187. Deferral of examination, 139 Disease prevention
See also Outpatient charting and Definitive diagnosis, 52–53 CDC. See Centers for Disease Control
communication Delivery note, 83–86 and Prevention (CDC)
Comorbid conditions, 220 Demographic information, 80, 179 prenatal care documentation, 83

Index | 389
preventive care, 125 description of, 8–9 General assessments, 48, 220
purpose of, 55 error rates, 195–196 Generic substitution section, of
Disposition, in discharge order, 286 errors associated with, 206 prescription, 201
Documentation federal initiatives for, 204 Genetic diseases, 99, 135
alterations, 3 growth of, 206 Genitalia, examination of, 30
analyzing, 47–48 lack of standards for, 206 Genitourinary system, review of, 28
correcting, 3 qualified, 204–205 Geriatric Depression Scale (GDS), 160, 161
evolution of, 1–2 safety benefits of, 204, 205 Geriatric Health Questionnaire, 153,
general principles, 3–5 Electronic Prescriptions for Controlled 154–155
importance of, 1 Substances rule, 206 Geriatric risk factors. See also Older adult
legal considerations for, 2–3 E-mail, 185–187 preventive care visits
medical considerations for, 2 benefits of, 185 assessment of, 153–162
medical records, ICD guidelines, 173 concerns of, 185–186 cognition, 162
outpatient charting and communication, provisions for using, 186–187 depression, 160
183–187 Emotional abuse, 102, 105 functional impairment, 156
patient counseling, 28 EMR. See Electronic medical records gait, 162
patient education, 55 (EMR) mobility, 162
perinatal and postpartum care, 83–88 Endocrine system, review of, 29 nutrition, 156–159
prenatal care, 80–83 Environmental allergies, 25 sensory deficits, 159–160
preventive care visits, 126–139 EPR (electronic patient record), 8 Geriatric syndrome, 160
proven diagnosis, 53 EPSDT (Early and Periodic Screening, Glossopharyngeal nerve, 30
purposes of, 3 Diagnosis, and Treatment) program, 93 Growth charts, 94, 96–97
Dose designations, Appendix C Evaluation and management services, Growth screening, 94, 97–98
Downcoding, 7 5–6, 218 Guidelines for Adolescent Preventive
Drug Abuse Screening Test, 131, 133 Exercise, 126 Services (GAPS), 102
Drug allergies, 25 Eye examination, 29 Gynecological examination, 30
Drug Enforcement Agency (DEA) Eyes, review of, 28
controlled substances, 196, 199, 206
e-prescribing, 196 F H
prescription drug abuse, 197, 199 HDDA (Hearing-Dependent Daily
Facial nerve, 30 Activities) Scale, 159–160
Drug names
Falls, 160 Head circumference, 94
abbreviations, 199
Family Healthware, 135 Head examination, 29
look-alike and sound-alike, 195
Family history Healthcare Information and Management
in admission history and physical Systems Society (HIMSS), 9
E examination, 219 Health-care power of attorney, 165
Ear examination, 30 description of, 26 Health education and counseling, 139
Early and Periodic Screening, Diagnosis, risk-factor identification based on, 135 Health Information Technology for
and Treatment program (EPSDT), 93 in surgical history and physical Economic and Clinical Health Act
Ears, nose, and mouth/throat, review of, 28 examination, 221 (HITECH), 9–10
Eating disorders, 106 Federation of State Medical Boards Health Insurance Portability and
E-cigarettes, 102 (FSMB), 186–187 Accountability Act (HIPAA)
Education, Internet sources for, 187 Female genitourinary system, review of, 108 authorization, 11
EHR (electronic health record), 8 Fever, postoperative, 260 background, 10
Electronic health record (EHR), 8 FIST screening, 102, 104 consent, 11
Electronic medical records (EMR) Five Ws, 260, 264 covered entities, 11
barriers to, 9, 206 Flow sheets, 179, 180 description of, 10
benefits of, 8–9 Follow-up care, in discharge order, 287 electronic health-care transitions, 10
definition of, 8 Follow-up instructions, 56, 58 electronic PHI communications, 186
diagnostic test findings included in, 179 Food allergies, 25, 176 electronic protected health information
e-mailing of, 186–187 Food and Drug Administration (FDA), provisions, 186
health-care delivery functions of, 8 confusion concerning drug Health Insurance Portability provision
interoperability of, 9 names, 195 of, 10
meaningful use of, 9–10 Food diary, 128 individual rights, 11–12
system qualifications, 204–205 Fraud, 7 minors, 12
Electronic nicotine delivery systems Full liquid diet, 232 Notice of Privacy Practices, 12–13
(ENDS), 102 Full operative report, 271 patient rights, 11–12
Electronic patient record (EPR), 8 Functional impairment, 156 penalties for violating, 13
Electronic prescribing privacy policy elements, 13
adverse drug event reductions using, 203 G Privacy Rule, 10–13
barriers to, 206 Gait, 162 privacy violations and penalties, 13
benefits of, 205–206 Galant’s reflex, 108 protected health information,
certification issues, 206 GAPS (Guidelines for Adolescent 11, 13, 186
components of, 204 Preventive Services), 102 security safeguards, 13–14
cost considerations, 206 Gastrointestinal system, review of, 28, 107 summary of, 14
definition of, 203 Gender-specific screening, 136–139 violation of, 13

390 | Index
Health literacy, 126

Health maintenance, 125, 219
I in pediatric preventive care visits, 99
postoperative, 233–234
Health promotion ICD. See International Classification of pre-operative evaluation of older
defined, 55 Diseases (ICD) adults, 163
prenatal care documentation, 83 ICD-10, 6 shorthand for documenting results of,
Health Resources and Services Identification section, of history, 24 261–263
Administration (HRSA), 94 Immunizations See also vaccinations in surgical history and physical
Hearing-Dependent Daily Activities in admission history and physical examination, 223
(HDDA) Scale, 159–160 examination, 219 Laboratory tests, 54
Hearing loss, 159, 161–162 in adults, 139 Laterality, 48
HEEADSSS, 102–104 in children, 100 Latex allergies, 25
HEENT, 29–30, 107 Immunologic system, review of, 29 Lawton IADL Scale, 156
Hematologic system, review of, 29 Indication section, of prescription, 200 Lead exposure screening, 99
Hepatitis C screening, 137 Inpatient care Legal considerations, 2–3
HHS (Department of Health and Human consult note, 266–270 Level of service, 5–6
Services), 3, 5, 219 daily orders, 260, 264–266 Living will, 165
HIPAA. See Health Insurance Portability daily progress note, 257–260, 261–263 Lymphatic system, review of, 29
and Accountability Act (HIPAA) full operative note, 271
History operative note, 271
admission history and physical procedure note, 272–273 M
examination, 218–221 Inscription section, of prescription, Male genitourinary system, review of, 107
chief complaint, 24–25 199–200 Malpractice
comprehensive. See Comprehensive Institute for Safe Medical Practice documentation involving laterality, 48
history and physical examination (ISMP), 234–235 lack of patient counseling on risks of
family history, 26, 135, 219 Instrumental activities of daily negative health habits, 28
identification section of, 24 living, 156 patient education documentation, 55
medical admission, 218–221 Insurance, hospice services, 166 prenatal test result documentation, 82
older adult risk factors, 153–160 Integumentary system, review of, 29 professional liability for vaccinations,
past medical history, 25–26, International Classification of Diseases 100
218–219, 221 (ICD) Mammogram, 126, 137
review of systems, 28–29, 219–220 description of, 5 Maternal and Child Health Bureau
sexual, 132–133 evaluation and management services, (MCHB), 94
social history, 26–27 6–7 Maternal history, prenatal care
surgical history and physical ICD-10, 6 documentation, 80–81
examination, 221–223 medical record documentation, 173 Medicaid, 186
History of the present illness (HPI), 25, Internet for medical education, 187 Medical admissions, 257–259
218, 221 Interoperability, of electronic medical assessment, 258
HITECH (Health Information records, 9 objective, 258
Technology for Economic and Interpreter for H&P, 25 plan, 259
Clinical Health Act), 9–10 Interpretive services, 219 subjective, 257–258
HIV screening, 137 Interventions Medical billing and coding, 5–7, 179
Hospice, 166 admission orders, 228 Medical history
Hospital done during the visit, 50–51 description of, 127–128
admitting patient to. See Admitting not done, 226 pediatric, 94, 95
patient to hospital perioperative orders, 232 Medical records
adverse drug events in hospitalized Intimate partner violence (IPV), 133–134 credibility uses of, 2
patients, 228, 234 Intravenous therapy, 228 dictating of, 83, 237, 271, 288
Code of Federal Regulations (CFR), IPV screening and counseling, 137 prior, 183
medical records content for Medicare
hospitalized patients (42 CFR J e-mail communications, 186
482.24), 217 The Joint Commission, medical records hospice services, 166
hospital course in discharge content for hospitalized patients, 217 Medicare Improvements for Patients and
summary, 290 Providers Act, 204
The Joint Commission, medical records K Medicare Modernization Act of 2003, 204
Medication history for hospital admission,
content for hospitalized patients, 216
Katz Index, 156 218
medical records content for hospitalized
patients, 217 Medication list
patient elopement from, 293–294 L description of, 176
patient leaving, against medical advice, Laboratory data, prenatal care in past medical history, 25
291, 293 documentation, 82 sample, 177
Hospital course, 290 Laboratory studies Medications
HPI (history of the present illness), 25, in admission history and physical in admission order, 228–229
218, 221 examination, 220 adverse events, 201
Hyperlipidemia, 135 in admission orders, 229 in discharge order, 286–287
Hypertension screening, 137 description of, 32 list of. See Medication list
Hypoglossal nerve, 30 outpatient, 179 older adults, 153, 155

Index | 391
perioperative, 232 Noncompliance with medical treatment, preoperative, 229, 230

reconciliation, 228–229 179, 181–182 special instruction, 229, 234
symptomatic, 229 Noncontrolled substances OSHA (Occupational Safety and Health
Medicolegal alert description of, 199 Administration), 134
adverse medication events, 201 prescription writing for, 199–201 Osteoporosis
consent, 273 Nonpharmacological treatment, 55 caused by eating disorders, 106
copy/paste notes, 259–260 Nose examination, 30 genetic tendency, 135
deferred examination, 139 Notice of Privacy Practices, 12–13 screening, 137
follow-up instructions, 288 NPO, 232 Outpatient charting and communication
fraud, 7 Nutrition advance directives, 165
health-care POA, 165 information, 27 billing information, 179
interpreter services, discrimination, 219 Mini Nutritional Assessment—Short demographic information, 179
intervention not done, 266 Form (MNA-SF), 156, 159 documentation of communication,
laboratory tests during pregnancy, 82 National Health and Nutrition 183–187
lack of patient counseling on risks of Examination Survey (NHANES), 97 flow sheets, 179, 180
negative health habits, 28 Nutritional Health Checklist, 157–158 medication list, 176–178
laterality, 48 Nutrition Checklist warning signs, 158 noncompliance with medical treatment,
medication list, 176 in older adults, 156–159 179, 181–182
patient education documentation, 55 prenatal care documentation, 83 overview of, 173
patient noncompliance, 182 risk-factor identification, 126, 128 patient portal, 187
proven diagnosis documentation, 53 prior medical records, 183
vaccination refusal, 100 problem list, 173–176
Men, screening for, 138–139 O referrals, 182, 183
Mental status, examination of, 30 Occupational history, 134 Ovarian cancer, 135
Mini-Cog test, 162 Occupational Safety and Health Overweight, 97
Mini Nutritional Assessment—Short Administration (OSHA), 134
Form (MNA-SF), 156, 159 Oculomotor nerve, 30
Minors, 12 Office for Civil Rights (OCR), 219 P
Mnemonics, 25, 26 Older adult preventive care visits. See also Palliative care, 166
Mobility assessment, 162 Geriatric risk factors Palmar grasp reflex, 108
Moro reflex, 108 advance directives, 165 Papanicolaou test, 137
Motor strength testing, 30 balance and mobility assessment, 162 Parachute reflex, 108
Mouth, review of, 107 cognitive assessment, 162 Parents’ Evaluation of Developmental
Mouth examination, 30 functional impairment, 156 Status (PEDS), 99
Muscle strength grading, 30 Geriatric Health Questionnaire, 153, Past medical history (PMH), 25–26,
Musculoskeletal examination, 30, 109 154–155 218–219, 221
Musculoskeletal system, review geriatric syndromes, 160 Patient-controlled analgesia, 232, 233
of, 29, 108 hospice and palliative care, 166 Patient counseling on risks of negative
“My Family Health Portrait,” 135 medication use, 153, 155 health habits, 28
mental health screening, 160, 161 Patient identification section, of
nutrition, 156–159 prescription, 199
N overview, 153 Patient portal, 187
Narrative format, for documenting pre-operative evaluations, 162–164 Patient(s)
objective information, 47–48, 49 risk factor assessment through history communication with, 183–187
National Child Abuse Hotline, 106 taking, 153–160 education of, 55–56
National Childhood Vaccine Injury Act risk factor assessment through physical media use by, 187–188
(NCVIA), 100 examination, 160–162 noncompliance with medical treatment,
National ePrescribing Patient Safety sensory deficit screening, 159–160 179, 181–182
Initiative, 206 sensory examinations, 161–162 rights of, under HIPAA, 11–12
National Health and Nutrition USPSTF screening recommendations, Pediatric preventive care visits
Examination Survey (NHANES), 97 162 age-specific physical examinations, 106,
National Institute of Drug Abuse Olfactory nerve, 30 107–108
Modified Alcohol, Smoking, and Operative note, 271 anticipatory guidance, 100–102
Substance Involvement Screening Optic nerve, 30 body mass index, 98
Test (NIDA Modified ASSIST), 131 Oral cancer, 134 components of, 94, 97–106
Neck, review of, 107 Oral health, 134 developmental screening, 98–99
Neck examination, 30 Orders growth screening, 94, 97–98
Neglect, 102, 105 admission, 223, 225–229 immunization status, 100
Neurological examination, 30–31 Computerized Physician Order Entry laboratory screening tests, 99
Neurological reflexes, 106 (CPOE), 235–237 overview of, 93–94
Neurological system, review of, 29, 108 daily, 260, 264–266 risk factor identification, 102–106
New Ballard score, 87 diet, 228, 230, 232 sports preparticipation physical
Newborn physical examination, 87, 88 discharge, 285–288 examination, 106
NHANES (National Health and perioperative, 229–234 PEDS (Parents’ Evaluation of
Nutrition Examination Survey), 97 postanesthesia care unit, 229, 231 Developmental Status), 99
NIDA Modified ASSIST, 131 postoperative, 230, 234 Percentiles, 97

392 | Index
Perinatal and postpartum care statistics regarding, 195 Referral

documentation, 83–88 Prescription writing defined, 182
delivery note, 83–86 abbreviations used in, 203 letter sample, 183
newborn history and physical authority for, 196–197 Referring provider, 182
examination, 88 controlled medications, 201, 203, 205, 206 Refill information section, of prescription,
newborn physical examination, 87 errors in, 195, 202–203, 228 200–201
postpartum note, 86–87 noncontrolled medications, 199–201 Reflexes, 31, 108
Perioperative orders, 229–234 prevalence of, 195 Rehabilitation Act of 1973, 219
Personal habits Preventive care visits Religious beliefs, 27
review of, 26–27 adult, 153 Respiratory examination, 30
risk factors associated with, 126 components of, 126 Respiratory system, review of, 28, 107
Pharmacological treatment, 55 definition of, 125 Review of systems (ROS)
Phenylketonuria (PKU), 99 documentation of, 126–139 admitting patient to the hospital,
PHI (protected health information), 11, gender-specific screening, 136–139 219–220
13, 186 health education and counseling, 139 comprehensive history and physical
Physical abuse, 102, 105 immunization status, 139 examination, 28–29
Physical examination older adult, 153 surgical history and physical
admission, 218–221 overview of, 125–126 examination, 223
age-specific, 106, 107–108 pediatric. See Pediatric preventive care visits Rheumatoid arthritis, 128
comprehensive. See Comprehensive risk factor identification. See Risk factor Rinne test, 161–162
history and physical examination identification Risk factor identification
description of, 29–31 Primary care provider, 182 alcohol consumption, 130–131
hospitalization, 218–221 Primary code, 7 blood product transfusions, 134
medical admission, 218–221 Primary prevention, 125 body mass index, 128–129
prenatal care documentation, 81–82 Prior medical records, 183 description of, 126
sports preparticipation, 106 Privacy, under HIPAA diet, 126, 128
surgical, 221–223 Privacy Rule, 10–13 exercise, 126
Placing and stepping reflex, 108 violations and penalties associated with, 13 family history, 135
Plan of care Problem list intimate partner violence, 133–134
admission history and physical admission history and physical nutrition, 126, 128
examination, 220 examination, 220 occupational history, 134
comprehensive history and physical comprehensive history and physical oral health, 134
examination, 32 examination, 32 pediatric, 102–106
surgical history and physical outpatient charting and communication, safety measures, 134
examination, 223 173–176 screening tests, 135–136
Plantar grasp reflex, 108 surgical history and physical sexual history, 132–133
Postanesthesia care unit order, 229, 231 examination, 223 substance abuse, 131–132, 133
Postoperative progress note, 260, 264 Procedure note, 272–273 tobacco use, 129–130
Postoperative orders, 234 Progress note, daily Rooting reflex, 108
Postpartum note, 86–87 content of, 257–260 ROS. See Review of systems (ROS)
Practitioner, defined, 196 description of, 257 RUSP (Recommended Uniform Screening
Preconception care, 137–138 medical admissions, 257–259 Panel), 99
Preexisting condition, 10 surgical admissions, 260, 261–263
Prenatal care documentation, 80–83 Prostate-specific antigen (PSA) screening,
demographic information, 80 138 S
health promotion and disease Protected health information (PHI), 11, Safety measures, 134
prevention, 83 13, 186 Screening(s)
laboratory data and diagnostic tests, 82 Providers abdominal aortic aneurysm, 138
maternal history, 80–81 communication with patient, 183–187 breast cancer, 137
nutrition, 83 DEA identifier number for, 197, 199 cervical cancer, 137
physical examination, 81–82 other, communication with, 182 colon cancer, 137
psychosocial factors, 83 prescription writing by. See Prescription Denver Developmental Screening Test
visits throughout pregnancy, 84 writing II (DDST-II), 99
Pre-operative evaluation of older adults, PSA (prostate-specific antigen) screening, 138 developmental, 98–99
162–164 Psychiatric system, review of, 29 diabetes mellitus, 137, 138
Pre-operative history, 289 Psychosocial factors, prenatal care diagnostic, 126
Pre-operative orders, 229, 230 documentation, 83 Drug Abuse Screening Test, 131, 133
Prescribers Early and Periodic Screening, Diagnosis,
identification of, 199
safeguards for, 197, 199
Q and Treatment program (EPSDT), 93
FIST screening, 102, 104
Quotations, 47–48 gender-specific, 136–139
Prescription form, 202
Prescription(s) growth, 94, 97–98
adverse drug events caused by, 203 R hearing impairment screening, 159
drug abuse, 196 Recommended Uniform Screening Panel hepatitis C, 137
elements of, 199, 200 (RUSP), 99 HIV, 137
illicit use of, 196 Rectal examination, 30 hypertension, 137

Index | 393
indications for, 126 differential diagnoses, 52, 53 Trunk incurvation reflex, 108
IPV screening and counseling, 137 follow-up instructions, 56, 58 Tuberculosis screening, 137
laboratory tests, 126 interventions done during the visit, Type 2 diabetes, 97–98
lead exposure, 99 50–51
for men, 138–139 laboratory tests, 54
mental health screening, 160, 161 Objective information portion of,
U
National Institute of Drug Abuse 48–51, 257 U.S. Preventive Services Task Force
Modified Alcohol, Smoking, and patient education, 55–56 (USPSTF)
Substance Involvement Screening Plan portion of, 54–58 hearing impairment screening, 159
Test (NIDA ASSIST), 131 procedure note, 272–273 medical conditions, 162
older adult medical conditions, 162 Subjective information portion of, risk factor identification based on
osteoporosis, 137 45–48, 257 screening tests, 135–136
pediatric BMI, 94, 97–98 therapeutic modalities, 55
pediatric laboratory tests, 99 Social history V
prostate-specific antigen (PSA), 138 in admission history, 219, 221, 223 Vaccinations See also immunizations
recommended types of, 136–139 in adolescents, 102 older adults, 162
Recommended Uniform Screening in adults, 26–27 refusal of, 100
Panel (RUSP), 99 Social media, 187–188 Vagus nerve, 30
risk factor identification based on, Social Security number, 179 Vegetarians, 128
135–136 Soft diet, 232 Vision testing, 160, 161
screening mammography, 126 Special instruction orders, 229, 234 Vital signs
sensory deficit screening, 159–160 Spinal accessory nerve, 30 in admission history and physical
sexually transmitted infections, 137, 138 Sports preparticipation physical examination, 220
tuberculosis, 137 examination, 106 admission orders, 227–228
USPSTF screening recommendations, 162 Startle reflex, 108 monitoring, 258
for women, 136–138 STI. See Sexually transmitted infection (STI) objective information, 48
Youth at Risk Screening Questionnaire, Stroke, 135 physical examination, 29
105 Subscription section, of prescription, 200 postoperative orders, 230
Secondary codes, 7 Substance abuse, 131–132, 133
Secondary prevention, 125 Sudden death, 106
Security, 13–14 Surgery W
Sensitive protected health information, 11 admissions, 260, 261–263 Wandering, 293–294
Sensory deficits in older adults, 159–160 history and physical examination, Warnings section, of prescription, 201
Sensory examinations, 161–162 221–223 Weber test, 161–162
Sensory testing, 31 pre-operative evaluation of older adults, Websites for medical education, 187
Sexual abuse, 102, 105 162–164 Well-child visits
Sexual history, 132–133 Systems heading format, for documenting components of, 94, 97–106
Sexually transmitted infection (STI) objective information, 50 description of, 93
adult preventive care, 133 Well-man examination, 138–139
email confidentiality, 186 Well-woman examination, 136–137
genitourinary review of systems, 28 T WHO. See World Health Organization
prenatal care documentation, 81 T-ACE questionnaire, 131 (WHO)
prenatal test result documentation, 82 Telemedicine, 186 Women
risk assessment, screening, and Telemetry, 221 screening for, 136–138
counseling, 137, 138 Telephone communications, 183–185 sports preparticipation physical
Signa section, of prescription, 200 Tertiary prevention, 125 examination for, 106
Signature section, of prescription, 201 Testes, 107 World Health Organization (WHO)
Skin, review of, 107 Therapeutic modalities, 55 growth standards, 94
Skin examination, 29 Throat examination, 30 health promotion, defined, 55
Sleep hygiene guide, 56 Timed Up and Go test, 162 International Classification of Diseases
Smoking, 129–130 Tinetti Performance Oriented Mobility (ICD), 6
SOAP notes Assessment tool, 162
Assessment portion of, 52–54, 257 Tobacco use, 129–130
description of, 45, 257 Trigeminal nerve, 30 Y
diagnostic test results, 50, 54 Trochlear nerve, 30 Youth at Risk Screening Questionnaire, 105


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Guide To Clinical Documentation 3rd Edition

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Debra o· 5 ull1van

Debra D. Sullivan, PhD, RN, PA-C

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Copyright © 2019 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: Melissa A. Duffield

Library of Congress Cataloging-in-Publication Data

Names: Sullivan, Debra D., author.

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Copyright © 2019 by F. A. Davis Company. All rights reserved. iii

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Copyright © 2019 by F. A. Davis Company. All rights reserved. v

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Copyright © 2019 by F. A. Davis Company. All rights reserved. vii

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Part 1: Foundations of Documentation

Part II: Documentation Related to Outpatient Care

Part III: Documentation Related to Inpatient Care

Copyright © 2019 by F. A. Davis Company. All rights reserved. ix

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Part 1: Foundations of Documentation

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Chapter 2 The Comprehensive History and Physical Examination 23

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Part II: Documentation Related to Outpatient Care

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Documenting Preventive Care 126

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Chapter 8 Outpatient Charting and Communication 173

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Part III: Documentation Related to Inpatient Care

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Vital Signs 227

Chapter 11 Documenting Inpatient Care 257

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Consult Note 266

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Copyright © 2019 by F. A. Davis Company. All rights reserved. xxi

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documentation and puts a greater burden on providers

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Application Exercise 1.1

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EXAMPLE 1.1  mortality and morbidity statistics. These standardized

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EXAMPLE 1.1 mortality and morbidity statistics. These standardized