The academic year is getting off to a hot start. I’ve been especially impressed by some exquisitely crafted admission notes written by the interns (i.e., the interns are on fire!). I know from experience, however, that if we’re not mindful, good habits can erode with time, so let’s pause to highlight some best practices:
- Chief Concerns should be written in full sentences that include age, gender (“man” or “woman,” not “male” or “female”), pertinent information (e.g., occupation, relevant illnesses) and the concern that brought the patient to medical attention. One or two words, like “dyspnea” or “abdominal pain,” are insufficient. Cramming irrelevant medical history into the Chief Concern is unnecessary and distracting. Here’s an effective CC: “Ms. B is a 76-year-old retired woman with COPD, admitted with cough, sputum production, and shortness of breath.”
- Critical Care Chief Concerns are used in the ICU to highlight what makes the patient critically ill. Separate Chief concerns are unnecessary. An example: “Ms. B is a 76-year-old retired woman with COPD, admitted to the MICU with cough, sputum production, shortness of breath and hypercapnia requiring noninvasive ventilation.”
- Histories of present illness should tell a story that includes a timeline and essential detail. Some good habits:
- Start with “The patient was in her usual state of health until...” If the patient is otherwise healthy, say “she was in her usual state of good health.” If she has a relevant underlying illness (e.g., well-controlled lupus), include that.
- Use time measures referring to the day of admission. For example, “The patient was in her usual state of good health until 2 days before admission when she developed rigors, fever, cough, and right-sided pleuritic chest pain. She took ibuprofen without relief. The symptoms persisted until the morning of admission when she became short of breath with minimal exertion and presented to the ER for evaluation.”
- Don’t confuse pertinent positives and negatives with the review of systems. Pertinent positives and negatives address findings relevant to the present illness. For example, in this case, they include sputum production, hemoptysis, recent travel, exposures to sick people, etc. In contrast, the Review of Systems is a general inventory that belongs after the family and social history. For this patient, the ROS might include questions about eyesight, hearing, joint complaints, etc.
- End the HPI with the events culminating in the patient’s admission. Emphasize the highlights while avoiding unnecessary detail like normal vital signs. For example, “In the ED, the patient had a temperature of 103.5oF, an SpO2 of 87% on RA, crackles in the right lung, and a CXR showing a dense, RUL infiltrate. She was given supplemental oxygen, 1g of ceftriaxone IV, and admitted to Fitkin.”
- The Physical Exam should include pertinent positives and negatives just like the HPI. For a patient with pneumonia, in addition to the findings you’d report for all patients, your should describe dentition (important if you’re considering anaerobic infections), adenopathy (if you’re considering chronic infections and malignancy), clubbing (suggesting chronic lung disease), and a thorough lung exam (presence or absence of respiratory distress, percussive dullness, asymmetric breath sounds, adventitial sounds such as crackles and wheezes, egophony, etc.).
- Assessment: This has three components.
- Summarize the salient features of the history and physical as well as the results of diagnostic tests, emphasizing your interpretation—not regurgitation—of the salient facts. For example, “This is a young man, presenting with a week of anorexia, abdominal pain, nausea and vomiting, with a physical exam notable for severe periumbilical tenderness, and elevated pancreatic enzymes.
- List the diagnostic possibilities: “Considerations include pancreatitis, esophageal rupture, and DKA, all of which can present with GI symptoms and amylase elevations.”
- Justify what you think is most likely given the data you’ve presented, supported by your medical knowledge and clinical reasoning: “Esophageal rupture would be unlikely in the absence of dysphagia or systemic toxicity. DKA is ruled out by the normal glucose and bicarbonate. Given the patient’s history of heavy alcohol use and the elevated lipase, in addition to the amylase, I think the patient has pancreatitis.”
- If you think a less likely but dangerous diagnosis is still possible (e.g., gastric perforation), say so.
- List concise Plans, employing simple phrases and words for clarity. For example, for a patient admitted for CHF:
- Check an echo
- Begin furosemide, aiming for 1L diuresis
- Wean oxygen as tolerated
- Follow daily weights, I’s and O’s
- Monitor electrolytes
- Continue home lisinopril and spironolactone
- Consult CHF team (followed by them as an outpatient)
- Resident addenda: All intern admission notes must be followed by a resident addendum, highlighting the key points and demonstrating that the work was a team effort. For example: “I saw and examined Mr. Jones with Dr. Smith and agree with her findings, assessment and plan. In summary, Mr. Jones has a history of intravenous drug use and presented with one day of fever and chills. Physical exam findings are notable for a new holosystolic murmur heard best at the left lower sternal border, an echocardiogram showing a tricuspid valve vegetation and severe TR, and blood cultures that are already growing gram positive cocci in clusters. We will start vancomycin and oxacillin until we know the sensitivities of what we presume to be S. aureus. Further details are as outlined in Dr. Smith’s thorough admission note.”
- Make the work your own: Your note should be your history, your physical, your assessment, and your plan. Information provided by others should inform your work but not dictate it. Most importantly, you must NEVER copy and paste someone else’s work. At some point we’ll have a discussion about the wisdom of copying forward your own work, but copying and pasting someone else’s work is never allowed. Tell us what you’ve discovered, what you think is going on, and how you plan to treat your patient.
I’m inspired by the fine work I’m already seeing this year, so please keep it up. And please do your best to stay cool on this scorching Sunday! My fingers are sizzling as I tap out 30+ fellowship letters of recommendation, but at least we have central air,