Hi Everyone

Our unit has recently changed to electronic documentation of daily progress notes but we find it very difficult to unite everyone on one uniform progress notes so that everyone in the unit write on same format. this will ultimately help to shorten the discharge summary at the end of newborn NICU course and easy to dictate plus also it will help to familiarize any one to get an impression of what is going on with he patient currently and what has happened in the past without going through each and every note.

I was wondering those who have electronic charting in their unit, how they cope with it. is there a fixed check mark notes template or you create your own note, if yes what would you include in your notes especially main headings and how you daily update your note.

Any help /feedback will be highly appreciated.

Naveed 

I guess you mean progress notes as "text" (?)

We use electronic patient records as well and use two types of notes that help us remember everything and help us write the discharge summary. Every week we write a "weekly note" that summarize the past week, under a standardized set of "tags" (Respiration / Cirkulation etc-etc). We also write up a "summary note" 1-2 times a month, that is more like a discharge note up to that timepoint.

With our electronic system it is possible to "copy a note to a new note", which makes these summarizing notes rather easy to keep update.

Thanks Stefan. Exactly what I mean that. The same is true here as well but  the problem is too many people write in their own style and don't update it daily which result in unnecessary details or old stuff carried forward. we do also have cut and paste facility which we use by copying the previous day note and paste it in new date and modify /update it. I need to ask few question

1. How do you avoid or make sure previous note is not carried forward without being updated?

2. Do you write week end summary note in the system or outside the system ( i mean where daily progress notes are auto populated or a separate folder.

3. Do you write with problem based approach or system based approach?

4. How do you approach with problems which are resolved , whether you remove them from notes or put them under separate headings in same note?

5. What about daily stuff like PEEP increased /decreased, urine out put, Ins and Output charting, examination findings

What I want that everyone in unit should follow the same format and for this I want to form a uniform template acceptable to all, which is easy to follow, assist in discharge summary etc 

Would love to see a typical progress note template you use, if possible can you please share ( of course by removing patient informations) or inbox me and also weekly summary format and discharge summary.

Thanks in advance for your help

Naveed

@rehman_naveed to have everyone writing in the same style and format , that is challenge  I doubt a medical record in Swedish would make much sense for you but I post here how the notes are constructed.

For any kind of notes for both dr's and nurses (admission note, daily/weekly notes, discharge report etc-etc) we have fixed templates. It is possible to write everything under the first headline (which is the note typ name), but most people sort the information by the defined headlines.

So, my best advice to you is to make templates and start to educate how to use them. As with everything else, the story-telling of medical information needs education and practise.

In principal we have the following structure:

Quote

NOTE TYPE (the note "category")
typically some general info here, like "Born at week 29+6, BW 1267, today at week 30+4, weight 1189. Generally well and stable."

The heading per system is similar for all note types (daily note, weekly note, summary note). I may have missed some headings, as I am not by a hostpial computer right now.

• Respiratory status
• Hemodynamic status
• Water balance
• Nutrition
• Hematology incl hyperbili
• Infection
• Neurology
• Family / social circumstances
• Summarising evaluation and plans

Regarding your questions above:

1. we preach the necessity of doing good notes

2. we write everything in the same electronic system

3. Like above, i.e. system based approach

4. In the weekly note, we summarize only the previous week. But in the "Summary Note" - that includes info from birth and till current date, we include everything, also resolved problemn. For example the Respiratory headline in a Summary note may be something like "CPAP from birth, but developed x-ray confirmed RDS and given surfactant (INSURE) at 12 hours. CPAP until DD/MM, HFNC from DD/MM until DD/MM, and without support since DD/MM. Supplemental oxygen until DD/MM."

5. Well, our daily bedside work is still on paper... so this is where details are available. However, we want the important numbers in the note (the Respir headline), and most importantly the planning (what to do at certain developments in O2/CO2 , etc)

https://resident360.nejm.org/content_items/note-to-self-principles-for-better-documentation/

A useful introduction to the problem.

I'll make my comments inline and in bold so you can see:

 

On 8/17/2017 at 7:29 PM, rehman_naveed said:

Thanks Stefan. Exactly what I mean that. The same is true here as well but  the problem is too many people write in their own style and don't update it daily which result in unnecessary details or old stuff carried forward. we do also have cut and paste facility which we use by copying the previous day note and paste it in new date and modify /update it.

There is nothing wrong with using the copy forward functionality as long as attention is paid to the accuracy of the note one is signing on that day.  I have seen team members use several strategies to assist in this: 1) making certain parts of the daily note as generic as possible.  Thus the respiratory plan might just says 'Titrate vent settings to support ventilation, oxygenation.  Blood gas and X-ray as needed'.  2) Historical information is identified by calendar date not a day of the week or a relative reference 'Patient is now s/p ex-lap and lysis of adhesions on MM/DD/YYYY by SURGEON' instead of 'POD#2 ex-lap, lysis of adhesions' - the former is always true, the later needs to be changed daily to remain true 3) Use different font, bold, italics, underline feature for elements which are new that day and especially if they are likely to become false if left unchanged on future days 'start antibiotics'

 

I need to ask few question

1. How do you avoid or make sure previous note is not carried forward without being updated? This is not possible.  We simply must encourage best practice and tell each other when we notice such oversights.  I work with medical trainees and I try to make a game of it.  I buy lunch or coffee for the resident who finds the most errors in my notes caused by copy-paste.

2. Do you write week end summary note in the system or outside the system ( i mean where daily progress notes are auto populated or a separate folder. Our junior trainees keep such notes which I review.  At the fellow & attending level, this information is conveyed in a verbal (usually face-to-face) signout ever Friday for a weekly summary and every 3-4 weeks for a more global summary.

3. Do you write with problem based approach or system based approach?  It depends on the patient.  Our template is system based and we follow this for 'routine' cases like prematurity, hypoglycemia, hyperbilirubinemia etc.  However, we also have a referral ICU that gets many surgical patients or referrals for evaluation and management of very specific problems.  In such cases, it is often more logical to use a problem based approach.

4. How do you approach with problems which are resolved , whether you remove them from notes or put them under separate headings in same note? Our EMR supports marking of problems as 'resolved' which moves them to another part of the EMR.  Within our notes, we keep the problem and mark as resolved if we are continuing to monitor for recurrence of the problem or if knowledge of the problem is informing our present management (i.e. current feeding intolerance, h/o medical NEC).  We also try to give every patient an assessment which is not just a problem list but an actual prioritization of the issue(s) we are actively managing.  Many of us will put important resolved problems into our assessment if they inform our global view of the child.

5. What about daily stuff like PEEP increased /decreased, urine out put, Ins and Output charting, examination findings We do NOT chart ventilator settings in the note because they are charted by respiratory therapists within the EMR.  Our template has a generic statement saying we reviewed data charted by rt, rn, etc. and reviewed labs & in/out which are also in another area of the EMR.  If specific data elements are important to that day's plan we may comment on them, but as a rule we do not automatically have them in the daily note.  I will note that my colleagues in pediatric critical care use a different note template that DOES auto-populate current vent settings on all patients.  I am not sure which is better.

Physical exam is in every daily note.  I try to make my daily exam as limited and generic as possible so that I can change it as little as possible from day to day for chronic patients.  This is a MAJOR source of copy-paste errors in our ICU.  I often find patients exam saying 'orally intubated' for days after extubation or 'CPAP prongs in place' even after intubation.  Or patient changed to high frequency vent and still having a very detailed cardiac exam described.

What I want that everyone in unit should follow the same format and for this I want to form a uniform template acceptable to all, which is easy to follow, assist in discharge summary etc 

I would try to separate the goal of good daily documentation from efforts to make discharge summary easy to write.  Our practice is that the monthly summary note written by the trainees is actually a discharge note in progress.  The person writing the discharge note is thus likely to only need to review past 2-3 weeks to complete the discharge summary and it is likely this person has cared for the child themselves over those weeks so summarization will be easy.

 

On 8/17/2017 at 7:29 PM, rehman_naveed said:

Would love to see a typical progress note template you use, if possible can you please share ( of course by removing patient informations) or inbox me and also weekly summary format and discharge summary.

Thanks in advance for your help

Naveed

 

The most important is that the patient should get benifit from our writing

Interpretation of patient condition to good assessement and planing for the coming 24 hours