Progress Note .... Could u help me !!!

[BaBiNa]

Salam everybody

2 weeks left for my internship beginning .... and no one teach me how to write correct progress note !!!

:shok:



I'll tell u story .......

:biggrin:

at my 1st day ... I was attached to one resident "who supposed to teach me"

I asked him to teach me how to clerk & write progress note

he just looked to Pt "without examination" and wrote few words in the file and put his stamp

then he looked to me and told me:

"It's simple like that .... TWO WORDS are enough"

:shok:

for me ..... It was the shortes P.N I had ever seen !!!!

:blink:





His way wes unsatsfied for me ..... :angry2:

So I keep writing the P.N by my way ... hahahahahahaha

:biggrin:






last week ... I saw medical student read and copy from the file of my Pt.

I asked him ..." Do u need any help or want ask anythings about this pt ? "

he said " Thanks doctora ... just I liked ur way in writing P.N and I want copy it"

:shok:

"Really !!!! ....... Thnx ...... but don't copy my P.N ...!!

cuz I'm new intern and nobody teached me the correct way "

"But ur P.N was the best one I had ever read in this hospital ..!!

I like it and I want write like yours in the future"

:shok:

"mmmmmm ... ok ... let me search about standerd way in writing P.N and I'll tell u

cuz I don't want teach anyone something may be it is wrong"

" ok ..... Thnx alot doctora"

then I left him & he still copying my P.N !!!

:shok:


I was SCHOKED ..... cuz this student copy my P.N .... that I created from my mind!!

:mellow:

hahahahahaha





So, I want know the standerd way in writing good P.N .... Could anyone in this

forum teach the new junior intern who know nothing :blush2: ???



Deep Thnx

:good:

[BaBiNa]

I'll put copy of my P.N

and want someone to correct it for me

REALLY ..... I Don't know ... how to write !!!!

:blush2:


--------------------------------------

11.8.29
9:00 am

Diagnosis: Lt side hemiparesis

Hx:

65 years old male K/C of CVA before 3 years with Rt side weakness admitted
through ER C/O complete Lt side weakness, aphasia & dysphagia for 2 days perior to admition


Today:

he is unconscious, can't open his eyes, No withdraws to pain , lying on the bed, connected to IV line, O2 nasal canula & folly catheter


P/E:

* V/S :
T= 37ْ C
P= 85 bpm regular
BP=170/90
RR= 20 breath/min

*CVS:
normal heart sounds , no murmurs
S1 + S2 + 0
No L.L edema

*Chest:
Equal air enrty bilatrly
Vesicular breathing
fine crackles in the Rt side


*Abdomen:
Soft, Not tender
No organomegaly
+ve B.S


*CNS:
- Higher mental function:
unconscious, GCS= 5/15

- Cranial Nerves:
can't be assessed

-Motor:
Upper limb:
Rt side : Hypertonia and Hyperreflexia, Power can't be assessed
Lt side : Normal tone and no reflexes, Power can't be assessed

Lower limb:
Rt side : Normal tone, No reflexes except ankle and planter reflexes, Power can't be assessed
Lt side: Normal tone , No reflexes, Power can't be assessed


Inv. :
" I write the last important lab results "


Medication:
" I write the medication that the pt still taking"


Plan:
See doctor's orders

---------------------------------------



Waiting for ur evaluation

:blush2:

[zizo]

Salam Dr Babina, very nice thread, really writing a good and informative progress notes should be a priority to any intern, as you said most doctors just write two or three lines to prove that they saw the patients, but I believe that there is a good way to write progress notes.

I think your notes are very nice and good mashallah, but here are my advices for you:
- Writing Progress notes is not like writing history and physical exam when you see patient in ER for first time, in progress notes we just write follow up of new changes of patients and new complaints and wishes and improvements in SOAP format, but of course you have to have a background about the case in the beginning like what you wrote but not necessarily daily.
- Always start by date and time and label your notes (Medical Progress Notes).
- SOAP stands for (Subjective = what patient tells you, Objective = what you discover in examination and investigations, Assessment = your overall opinion about patient today in details, Plan = any new orders or just Continue Present Management CPM or Continue Same Treatment CST)
- In S, ask the patient about the complaints which he came with if changed or the same, then specifically ask about any pain or fever or other new complaints and any wishes.
- In O, start by vital signs which are always the most important and look for the chart, in temperature look for any fever and note the T max or the highest temperature and at what time it was, and also see BP for any drops or hypertension attacks, also the other vitals, then examine mainly the system related to the disease or chief complaints e.g. if CVA patients examine mainly CNS noting any changes than before, plus other systems if you suspect any thing abnormal.
- Look for CBC, U&Es, ABG, Coagulation profiles, CXR, ECG daily in general and also check if any CT scan or MRI for example was supposed to be done or histology or biopsy result or any other test or procedure like for example LP or Ascitic fluid analysis, and try to contact the lab or radiology department to get the results earlier.
- In A, Assessment means you write what you think is going on with your patient, may be it is not very important at intern level but a consultant once told me that the Assessment part is the most important part of your note and should be the longest and most comprehensive to summarize what you think is your patient's problems.
- In P, you write your new orders based on what you found, many times especially in chronic and long stay patients nothing new will happen so simply write Continue Same Treatment or commonly CST, but my advice to you is to consult your senior when you want to write any new orders to protect yourself and the patient but in the same time be self confident and have your own opinion and impression. You can start writing simple orders to practice by your own if the patient need it e.g. Paracetamol 1g PO tid PRN if patient has mild pain or fever.
- Always write all the medications and IVF your patients on especially any antibiotics in which you should also write the day number e.g. Ceftriaxone 1g IV Bid Day no. 2 and also always write the generic name NOT the trade name. Don't forget to write also insulin sliding scale which may not be in the medication sheet, it might be in a separate paper. Either you write the medications in the bottom before the plan or in the side of the paper.
- Read the orders of the previous day and make sure all the tests requested are done and follow up the results and try to have a copy of it e.g. biopsy result.
- There are other things you may need to write but not in all cases like for example Input/Output chart in which you calculate total intake by patient (oral, NGT or IV) and total output mainly urine and NG aspirate or others, and of course in other settings like ICU for example you have to be so meticulous and write everything about your patient but we are talking in general here.

Here is a very informative website from Columbia University in USA showing exactly how to write a good progress note:
http://cpmcnet.columbia.edu/dept/ps/2002/home1.html

and here is an example of a good medical progress notes:
http://cpmcnet.columbia.edu/dept/ps/2002/SOAPmed.html

Another book helped me a lot to know what I should check daily in my patients and how to write it was Surgical Recall, in the first few papers there is a very good explanation about this.

I will comeback with other points later, Salam for now.

[H@SSOOM]

SOAP approach is excellent,,, I've heard about it from Dr. Almoallim.... and it seems to be explain wounderfuly by zizo.....

hehehe I am still remembering your purple pen dear zizo in Al-Noor ... do u still remember it? hahaha it used to write cool notes.....

[BaBiNa]

Dr.zizo

WaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaW

AMAZING !!!!

:yahoo:

Thnx

Thnx

Thnx

Thnx

Thnx

Thnx

Aloooooooooooooooooooooooooooooooooooooooooooooot




Really deeeeeeeeeeep Thnx for great explaination and nice links

:good:




Today morning, I went to hospital & I want try writing P.N after ur explaination!!

:grin:

BUT ........ today was my 1st day in ICU and the H.O.D told me not to do anything

just be observer for couple days !!

:huh:

Then I can write P.N and next week I can do procedures !!

:biggrin:

So, I had a look for ICU's P.N, it was more organize & better than I saw in medical words

:good:





and of course in other settings like ICU for example you have to be so meticulous and write everything about your patient but we are talking in general here.

mmmmm, I want ask for other favor Dr.zizo ... could I !!!

:blush2:

what are extra points "high-light points" in ICU's P.N differ from Medical P.N???

:rolleyes:





>>> I feel that one day u will hate yourself to be moderator in this section cuz of me ..hahahaha

:biggrin:







Really deep thnx .... GOD Bless u in all times

:good:

New junior intern,,,

[zizo]

Hassoom that purple pen is my trade mark lol but u know, sometimes people will catch u easily when u choose a unique colour :biggrin:
anyway thanks for ur words

Dr Babina
I am so happy u found it useful, please ask whatever u want and I will do my best to give u what I know..
Regarding ICU notes honestly I am not an expert in that but as I told u it should be more detailed and they usually write each system alone e.g. Cardio, Neuro etc..
I will look for it and u please also look for it and lets try to find the best way here..

I'll be back soon
Salam

[dr.storm]

nice progression note i like it

[BaBiNa]

ICU Progress Notes


It's same like medical P.N, but there are some points important in ICU P.N



- In vital signs (BP, P, RR, T) they add :

sO2 "O2 saturation"

CVP "Central Venous Pressure"

some notes, instead of V/S .. they write "Heamodynamically"




- All procedures must be writing in P.N after insertion "in same day" and next days

must wrtite ur comment on those lines and tubes , e.g : ETT, ICT, Folly catheter ... etc

for example : ETT size "7" was inserted and fixed at 22 cm, then the Pt connected to M.V:
Mood : ??
PEEP: ???
iFo2: ???
F: ???
Vt: ???





- If pt on M.V "Mechanical Ventilator" , u must write that everyday with some comments on :

Mode : SIMV or CMV

PEEP "Positive End Expiratory Pressure"

F " Frequency ... I think it means R.R"

Vt "Tidal Volum"

Fio2 "Fraction of Inspired Oxygen"







- U must comment on Sedations & Muscle Relaxents in each pt in ICU, e.g:

If pt on sedations & Ms Relaxents, u wrtie:

(Pt is sadative & paralyze) or ( Pt on "name of sadetions+dose" & "name of Ms Relaxents+dose")

If pt not on sedation or Ms Relaxents, u write:

(Pt is not sadative or paralyze) or (Pt is not on sadations or Ms relaxents)






- Before u write the V/S, u must comment if pt on inotropics or not, if he is on inotropics mention the dose and freqency






mmmmmm .... that what I noted in ICU P.N within my last week in ICU

:biggrin:

Hope It useful 4 u & u get benefit
:good:






If I find more ... I'll come back & write here

See U
:bye:

[BaBiNa]

Dr.zizo

about purple pen, there are 2 doctors in ICU-Al zaher write thier orders by this color

:biggrin:




mmmmm also me !!!

:blush2:

cuz I'm having passion on colors, each year I choose color for all my stuff

last year was orange, this year is purple !!!

may be I'll think to change it, cuz it's ur trade color and I don't want steal yours

hahahahahaha

:biggrin:

.

[aTHoB]

if you wrote with colours in National Guard PN,

You'll get a big fat OVA....!!

[dr.storm]

dr.babina u r great person i like ur acivity in every thing

ur friend : x

[PeDiaTroN]

Dr.zizo

Dr.BaBiNa



THANK YOU VERY MUCH !!


For your Marvelous Work





God Bless You All

[Dr.MHM]

thank you
;;;;;;;;;;;;