PA Excel - PM Group Student Page

  Welcome to our rotation! Please read ALL of the following. Watch the Rotation Basics Video Below FIRST. You must also watch a minimum of the following videos (on the PROVIDER DOCUMENTATION PAGE) BEFORE starting your rotation:

HOW TO WRITE A PLAN

BASE PHYSICAL EXAM TEMPLATE

EPIC CHART REVIEW

EPIC H&P DOCUMENTATION

EPIC PROGRESS NOTE DOCUMENTATION

AGASTHA OFFICE DOCUMENTATION

PLEASE NOTE: ROUTINE COPY AND PASTING FROM PRIOR NOTES WILL RESULT IN FAILURE OF THE ROTATION.

CHIEF COMPLAINT

If the patient does have an actual chief complaint you may put it here first in quotes. Regardless if the patient actually does have a true chief complaint, you should list here all of the active problems that you are dealing with regarding this patient. Please list the primary diagnosis for their admission first followed by the most acute things.  For example: Left hip fracture status post open reduction internal fixation, congestive heart failure, chronic obstructive pulmonary disease, uncontrolled diabetes.   Or  New onset “pain in my right leg”, Left hip fracture status post open reduction internal fixation, congestive heart failure, chronic obstructive pulmonary disease, uncontrolled diabetes.      

HISTORY OF PRESENT ILLNESS

Please list here are complete chronology of everything that is happening with the patient since the last time they were seen by you or in the last week preceding the time they were seen if you have not seen them before. If it’s a new admission please chronicle everything that’s happened to the patient since their previous admission to the acute care setting that brought them now to rehabilitation. Please remember to review everything in the chart especially the physician orders to make sure that you account for everything that’s happened to the patient. You may also adhere anything that you believe is important regarding laboratory findings the clinical condition of the patient or what your considerations are going forward with treatment plan.

PHYSICAL EXAM

We will be using the following PE template for outpatient settings. Templates help us to save time but should NEVER replace proper documentation of a good physical exam. Physical exam finding must be updated EVERY time you see a patient. Please note, section with "[]" or a "***" must be changed EVERY note and should NEVER be the same as the last note. 

CONSTITUTIONAL: Vitals as above 

EYES: Conjunctiva clear, no discharge  

EARS: External ears and nose without deformity 

NOSE: Nasal septum midline, No nasal drainage 

MOUTH: Oral mucosa lips and gums moist and pink  

NECK: No masses, trachea midline 

RESPIRATORY: []  

CARDIOVASCULAR: S1 and S2 [] 

GASTROINTESTINAL: [] 

SKIN: Warm, dry   

EXTREMITIES: [] 

LYMPHATIC: palpation finds no overt lymphadenopathy

Rules for PE documentation:

ALWAYS review the PE template from the beginning and ensure that it is in line with the physical exam you performed that day.

The 4 main sections (RESPIRATORY, CARDIOVASCULAR, GASTROINTESTINAL and EXTREMITIES) must be changed EVERY note and must ALWAYS be BOLD 

Any abnormal finding which you add to the physical exam MUST be BOLDED (When using Fluency Flex, please also add brackets [] around the finding: example [rhonchi]

LABORATORY DOCUMENTATION

When documenting lab findings in your note ALWAYS include a prior value if available for comparison. For example, if the patient's hemoglobin is 8.2, please document: "the hemoglobin is 8.2, down from 10.4 this morning." No lab should ever be discussed with the comparison available. 

ASSESSMENT and PLAN

When writing your plan, please use this template: (Please watch the videos as well)  Diagnosis/Assessment:      

Reason (why did this happen?)     

Current Status of the disorder (better, worse?)     

Recent review (what has recently been done? how did the pt respond to this action?)     

Action (what are you doing about this today?)     

Follow up     

EXAMPLE:  

Hypertension:      

Reactive due to IV steroids     

Compensated, at goal     

Responding to PRN hydralazine which was started 3 days ago     

Monitor closely, will be decreasing Solumedrol as PNA is improving     

Monitor BP closely with expectation of improvement with decreased Solumedrol  

An Assessment/Plan such as: "Hypertension: continue treatment" is never acceptable.     

In you progress note please document Therapy: 

Please list here all therapies that are involved with the patient. This normally includes a minimum of physical occupational therapy and often include speech therapy as well. Please list specifically what the patient is doing over the last 3 to 5 days regarding their therapy. Please see an example below:  

Physical therapy: the patient is walking 75 feet with a rolling Walker with minimal assist. This is improved from a prior of 50 feet with a rolling Walker last week.  

Occupational therapy: the patient is working with sit to stand mobility and is improving per my discussion with the therapist. They are improving with their activities of daily living however still require moderate assist with daily routines such as bathing and hygiene. Toileting is improving and the patient is now able to sit to stand to the bedside commode on her own.  

Speech therapy: the patient’s dysphasia is improving and the patient is now able to consume mechanical soft diet with supervision with the speech therapist. Per my discussion with the speech therapy Department today the patient’s dysphasia has improved as of last week when she required a puréed diet.