Do's and Don'ts of Documentation: Summary Statement

Do’s and Don’ts of Documentation

The Impression and Plan

Key concepts: Your impression and plan should include a component of medical decision-making.

Medical Decision-Making: the cognitive process by which you (the provider) draw your final impression and plan.  How did you get from your initial evaluation to your final assessment and plan?  This may include your interpretation of: essential history, key exam findings, relevant test interpretation, and validated medical decision tools/scores. It may also include your informed clinical subjective gestalt.

The following are a list of DO’S and DON’TS that may be considered to help broaden and clarify the Impression/Plan section of the note:

***Disclaimer:  WARNING; The following are only ideas, not absolutes.  This is, in NO WAY, an attempt to control your documentation.  It is merely a list of SUGGESTIONS, something to consider, and if nothing else an attempt to generate thoughtful conversation.  The list is malleable and further input/suggestion is encouraged.***

Re-introduction: You may consider reintroducing the patient prior to giving your impression.  The purpose of reintroduction is mainly communicative.  When other providers (clinical/admitting/consulting) read your note, they may benefit from a brief introduction of the patient. Most likely this information already exists in the HPI and it is worthwhile to consider repeating it prior to your assessment and plan.

-DO consider reintroducing the patient (restate the patient’s name or age and sex).

Example: “Mr Smith is a 55 yo male...”

-DO consider including a brief summary of medical history that will inform future readers regarding this specific presentation or which informed your medical decision making. 

Example: “With a history of 3 vessel CABG…”

                       

            -DO list the patient’s chief complaint or a more focused diagnosis if one is clear.

            Example: “Who presents with chest pain…”  

            -DO NOT list irrelevant history that is unrelated to the present visit. 

            Example: “With a history of eczema on the left small toe…”

Impression: Your summarized opinion of what is going on clinically. It is most ideal to have a specific conclusion however, sometimes you will need to leave things open-ended.

            -Example: “My impression is that this likely represents unstable angina…”

            -Example: “My impression is that this patient’s chest pain is non-cardiac…”

            -Example: “My impression is that the cause of this chest pain is still uncertain…”

            -Do consider including a phrase that indicates a thoughtful review. (This is not

            essential and you can choose to be more brief.)

Example: “After a review of the history, exam, and studies, it is my impression that Mr Smith’s chest pain is non-cardiac.”

Example: “After a review of the history, exam, and studies, the cause of Mr Smith’s chest pain remains unclear.”

*DO NOT repeat irrelevant details of the case, this should be a focused impression. (If details of the case are used they should be pertinent and succinct, not rambling.)

*Note: Some providers give their ‘medical decision-making’ prior to the impression.  They “lead into” the impression with medical decision-making.  Others give an impression and then follow it with a description as to how they got there.   Either method is perfectly acceptable and a matter of personal style. More important some form of medical decision-making (your cognitive process) should be included in your note.

Medical Decision-Making:

-DO describe your cognitive thought process.  What thoughts led you to form your impression and plan?

            -DO include risk stratification whenever appropriate.  This may include general disease prevalence, elements of the history/ROS/physical, relevant tests/studies, validated clinical calculators; which increase or lower a patient’s risk for the disease process that you are considering.

            Example: “Mr X’s pain was not sudden or severe at onset, his pulses are equal and symmetric in the upper and lower extremities, and the chest xray shows no mediastinal widening which decreases the likelihood (I am using “likelihood” and “risk” interchangeably) of aortic dissection.

-DO describe your reasoning for NOT obtaining a certain test that could be considered “standard” upon review.

Example: “I elected not to perform a CT Scan of the head in this 2 year old because…”

            -DO include patient input when influences the formation of your plan. 

Example:  “We discussed risks and benefits of test/treatment X vs Y and the patient prefers X.”

            -DO consider relevant opinions of consultants whom you discuss the case with.

            Example:  I discussed the case with ophthalmology who agrees with X,Y,Z…”

-DO address all components of your differential diagnosis.  If you list10 disease processes in your differential diagnosis for chest pain, you must address each one.

           

Example: if you list Aortic Dissection as a possible cause for chest pain, you MUST follow up with why or why not you are concerned about this process and what you have done to evaluate it

-DON’T make a long differential diagnosis list and fail to address each component directly. 

Example “I considered, unstable angina, PE, Aortic dissection, esophageal rupture, cardiac tamponade, pneumothorax, and aliens from outer space.”  (You should then briefly describe why you would ‘rule in’ or ‘rule out’ each diagnosis. You should describe your thoughts about each disease entitiy.)

            -DON’T discuss ancillary issues that are irrelevant to the main complaint.

Example: Patient who presents with severe chest pain and shortness of breath; “Mr X is concerned about his eczema today…”

            -DON’T include conflicts with consultants.

Example: “Surgeon AH does not think this is an appy and he is wrong and really mean too.”

(It is reasonable to document differences of opinion, but you have to explain why you are more or less worried than the consultant and do it in a way that remains focused on the patient, not on any personal grudge or power struggle with the consultant.)

           

-DON’T (or at least be careful about) using response to treatment as part of your cognitive process.  Only use response to treatment when proof of an improving disease process.

Example (NOT proof of improving disease process): “Ms X’s headache improved with dilauded so she unlikely has a SAH.”

Example (NOT proof of improving disease process): “Baby K’s fever improved with Tylenol and therefore she can’t possibly have a serious bacterial infection.”

Example (IMPROVING disease process): Mr Y’s arm tingling resolved and he is no longer a candidate for TPA.

PLAN:

            -DO describe whether or not the patient was admitted or discharged.

-DO mention relevant follow up plans for complicated or high risk discharge diagnosis. 

-DO describe return recommendations (or refer to your DC instructions) for high risk discharge diagnosis.

            -DO consider a brief description of the likely hospital course.

Example: “Will plan to follow troponins and consider cardiac stress test as indicated.”

(You have to be careful not to speak for the hospitalists/consultants and commit them to something, however, if you have the conversation with them, it is reasonable to document a probable course.)

-DO include relevant patient/family input regarding the plan.  (The bulk of family conversation should be listed in the chronological “time stamp” portion of the note, however, it is reasonable to include brief acceptance by patient/family regarding the final plan.)

-DON’T fail to mention a plan. 

            -DON’T detail a plan that is unrealistic.

Example: Mr X (who is quadriplegic and has cognitive delay) agrees to follow up with gastroenterology in 1 day. 

            -DON’T dismiss or abandon the patient prematurely.

            -DON’T create a plan without considering patient/family input.