ABSTRACT
Communication and patient care go hand in hand. Unfortunately, due to time constraints direct verbal communication with health care providers in every instance is not practical; it is also inefficient. Documentation is mandated by the Joint Commission on Accreditation of Healthcare Organizations and hospital bylaws. It reduces ambiguity and actually speeds communication between physician and hospital staff. Standard paperwork is recommended in most cases. Forms for patient admission, history and physical examination, daily patient rounds, preprocedural orders, consent form, discharge summary, and discharge orders allow the busy interventionalist to multitask with reasonable efficiency and fewer mistakes.
Keywords: Standard forms, interventional radiology, paperwork, patient care
Basic paperwork is mandated by hospital bylaws and reviewed periodically by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) audits; it is also a simple and effective means of communicating with physicians, nurses, laboratory staff, and others. There are established forms of communication necessary for patient care that will be reviewed in this article.
The management of the interventional radiology patient certainly involves more than simple paper work. However, there are six basic forms that can greatly increase efficiency, allowing the interventionalist to see the patient, perform the history and physical, and write preprocedural and admission orders, all within a 15-minute period. Use of physician extenders, fellows, and residents can further increase efficiency.
To perform as effectively as any other admitting physician begins with knowing what to write and order. This requires some advance preparation before patient arrival. Preprinted forms can be valuable in improving organization, readability, and efficiency, as well as making sure no detail is overlooked. When developing these forms, it is important to be aware of the essential information required in each section, as determined by Medicare, billing, JCAHO, and hospital bylaws. Obtain and familiarize yourself with a copy of your hospital bylaws to ensure that hospital-specific requirements are met. Necessary references, such as billing codebooks and the Society of Interventional Radiology syllabus, should be made readily available.
Furthermore, an efficient system requires solid teamwork. Guidelines should be developed detailing how each patient is approached. Team members must be trained and updated on any changes to protocol. These guidelines should address which preprinted forms need to be present in the patient's chart and the information that must be gathered prior to the interventionalist seeing the patient, including the appropriate laboratory workup and salient reports. At our institution, before the patient arrives, the appropriate imaging reports, laboratory results, prior history and physical examinations, and relevant reports from other physicians are collected and organized in the patient's chart. By the time the patient arrives at our preprocedural area, registration and laboratory blood draws have already been completed. The nursing staff gowns the patient, assesses and records vital signs, completes a nursing evaluation, and documents laboratory values when they become available.
The postprocedural order form (Fig. 1), history and physical form (Fig. 2), and procedural consent form (Fig. 3) have all been appropriately labeled and are ready to be completed. The interventionalist need only arrive punctually, review the chart information, perform a focused history and physical examination, and document the findings on our streamlined form. Informed consent is then obtained and the preprocedural orders are completed (Fig. 4). Once the patient has been treated and admitted, daily notes are written on the chart specifically addressing interventional radiology and other medical issues. When the patient is ready for discharge, a dictated discharge summary is added to the chart and discharge orders written. This should satisfy 95% of necessary chart documentation.
Figure 1.
Postprocedural order form.
Figure 2.
History and physical form.
Figure 3.
Procedural consent form.
Figure 4.
Preprocedural order form.
THE HISTORY AND PHYSICAL EXAMINATION
A targeted history and physical is usually all that is required. The interventional radiologist usually knows what the problem is before seeing the patient. This information is communicated to us by the requesting physician or the patient has previously been seen in our outpatient office. The disease processes are familiar us (e.g., peripheral vascular disease) and the patient's chief complaints are usually straightforward (e.g., “leg aches when I walk”). I cannot stress enough the importance of simple, easy-to-fill-out history and physical examination form. This can save a lot of time and still meet the basic requirements. Check boxes on the form are a plus! A detailed description of all the necessary aspects of a complete history and physical examination is given below for reference as needed.
The basic sections of a history and physical examination (Fig. 2) include the chief complaint, history of present illness, previous medical and surgical history, allergies, medications, social history, family history, review of systems, physical examination (including a vascular examination), laboratories and imaging results, impression, and plan. For interventional radiology, some of the most important pieces of data to be addressed include: location of symptoms (for planning access and therapy), medications (e.g., Metformin, which may need to be stopped for 24 hours, or blood thinners), allergies (especially to contrast; information about pretreatment if one is present), blood urea nitrogen (BUN) and creatinine (as a estimate of contrast tolerance), and prothrombin time (PT)/international normalized ratio (INR) (for postprocedural hemostasis).
As a reminder, the chief complaint must represent a symptom, not a diagnosis, and is often in the patient's own words. The history of present illness should elaborate on the chief complaint, addressing details such as location, severity, exacerbation, time course, associated/absent symptoms, and any associated conditions or surgeries related to the chief complaint. The previous medical history should include a list of diagnoses, and the surgical history contains a list of prior procedures including dates performed. As discussed above, allergies and medications are very important to be aware of. Social history should include marital status and the use of alcohol, drugs, or tobacco. Family history should address medical conditions related to the chief complaint in family members. The review of systems is a systems-based review of symptoms and conditions, including documentation of pertinent negatives. This serves to remind the patient of information that they may have forgotten to mention earlier during the interview.
The physical examination is performed to substantiate hypotheses generated by the history and obtain further information concerning the specifics of the patient's complaint to arrive at an accurate diagnosis and treatment plan. The physical examination also serves to alert the interventionalist to any comorbidity, which may require alteration of the proposed therapy or adversely affect outcome. The focused subspecialty physical examination should include the basic elements of the general physical examination but also elaborate on the presenting complaint as well as assess for any physical factors that may affect the planned intervention. The examination begins with vital signs and an assessment of the patient's overall well-being and then moves on to specific systems. The cardiovascular examination assesses rate, rhythm, and quality of heartbeat; the pulmonary examination evaluates respiratory characteristics; the abdominal examination appraises bowel sounds, tenderness, or distention; the neurological examination documents any preexisting deficits; the extremity examination with vascular examination assesses edema, skin changes, or ulceration. The head, eyes, ears, nose, and throat examination is performed when appropriate. Finally, focused examination is performed of any pertinent body parts for which the patient is being seen.
Laboratory data should be reviewed to identify abnormalities that may affect the intended intervention. Important values include PT/PTT (partial thromboplastin time)/INR and platelet level (for postprocedural hemostasis), BUN and creatinine (as an estimate of contrast tolerance), and electrolyte abnormalities. BUN and creatinine may determine whether carbon dioxide or Visipaque is used in lieu of standard contrast. In some cases, a temporary vascular access may be placed instead of tunneled access if the INR is severely elevated.
PREPROCEDURAL ORDERS
The preprocedural order and note can be handled as a standardized form (Fig. 4) in most cases. Some orders are universal to every case, although others are tailored to specific types of cases (e.g., angiograms, biopsies, or dialysis). The order sheet will need to satisfy your hospitals' particular bylaw requirements. The form shown in Fig. 4 used for our outpatients is detailed and should satisfy most hospitals. For inpatients the physician extender or physician writes a focused note, one paragraph in length, stating the history and chief complaint of the patient as well as a discussion of the procedure (either detailed or in general terms) and a sentence describing that the risks, benefits, and alternatives were discussed with the patient and informed consent was obtained. Premedication (including antibiotics), hydration, intravenous access needs, ASA score (American Society of Anesthesiologists risk score), and preprocedural laboratory work and imaging should be addressed.
CONSENT FORM
An example is given (Fig. 3) that highlights the necessities, again governed by your hospital bylaws. The requirements at our hospital include: name of the patient, technical description of procedure, description of procedure in laymen's words, date, signature of patient or authorized representative and the relationship of the authorized representative to the patient, person obtaining consent, and drug allergies of the patient. The consent form will also have general statements and consents to administer blood products or other medications as deemed necessary by the treating physician. Your hospital will likely have an alternate consent form for Jehovah's Witness patients.
ADMISSION NOTE
A senior resident passed this formula to me when I was a medical student. It is simple to remember and uses a nearly universal format. Just remember: ABC VANDALISM.
Admit: to whom; which unit; full or 23-hour observation (when in doubt use full admit)
Because (diagnosis): reason for admission
Condition: stable, unstable, guarded, or critical
Vital signs: type, frequency, and parameters for MD notification
Allergies: drug, food, tape, latex
Nursing duties: drain management, weights, intake and output
Diet: requirements/restrictions; nothing by mouth after midnight except for medications with sips of water
Activity: type and limitations, duration and frequency, position
Laboratories: preoperative, BUN, creatinine, coagulation profile, hemoglobin, and hematocrit
Intravenous fluids: types, rates, duration
Special: includes imaging (chest x-ray, ultrasound, and so on; when and reason) and consults (diagnosis, reason; call all consults)
Medications: home meds, additional meds, sleep, anxiety, anticoagulation, Plavix, and prophylaxis (antiulcer, deep vein thrombosis, antibiotics)
Talking with the patient's nurse and answering any questions he or she may have will save you from phone calls in the middle of the night. Remember that requirements for admission orders are hospital bylaw-specific, so obtain and familiarize yourself with a copy of your hospital bylaws. This order format should be adequate for most purposes.
DAILY NOTES
The daily note should be a brief update of the patient's status and allows for communication of the assessment and treatment plan between the different caregivers. We have used the SOAP (subjective, objective, assessment, and plan) note format for over a decade without any significant problems. Some physicians use preprinted, formatted SOAP notes for improved readability and efficiency.
Subjective: how patient perceives his status, any new complaints, issues, or questions. Better, same, or worse.
Objective: vital signs, limited physical examination, laboratory and imaging results, input and output and description drain including site evaluation, culture/ biopsy results. Limb evaluation when needed, groin puncture site evaluation. Include comparison to prior results, if relevant.
Assessment and Plan: these are usually lumped together as a problem-based list, starting with the interventional radiology-specific concerns. Each problem is followed by an assessment of the situation as well as the planned course of action, both diagnostic and therapeutic. A detailed list of all the medical problems is usually not needed unless the patient is your admission. A simple statement such as “hypertension—patient to take home meds” is appropriate.
DISCHARGE SUMMARY
Begin with a brief summary of the reason for admission with any pertinent symptoms, history items, physical, laboratory, or imaging findings on admission. The hospital course should include consultations, diagnostic and therapeutic procedures, and any pertinent physical, laboratory, or imaging findings during the course of the patient's hospital stay, as well as patient outcome. The final section includes the patient's disposition (e.g., to home or nursing facility), disposition condition, and a short summary of the highlights of the discharge orders, including changes to medication and follow-up studies or appointments. Many times the follow-up appointment to your office will not be scheduled at time of discharge. A statement such as “interventional radiology office to call patient and schedule follow-up” is appropriate.
DISCHARGE ORDERS
Include continued, discontinued, new, or adjusted medications (including dose, frequency, and duration of new medications), new medicine prescriptions, dietary and activity restrictions, wound and drain care instructions, and follow-up imaging, laboratories, or appointments. Phone numbers should be provided for contacts to address patient questions, problems, or concerns. For an overnight stay for, say, a renal stent, I will give the following restrictions: “Patient to resume normal activity immediately but no heavy lifting for 3 days, that is, nothing heavier than a gallon of milk. Have patient contact emergency room or call hospital and have interventional radiologist paged if swelling occurs at groin puncture site, fever greater than 100°F, severe flank pain, or syncope.”
CONCLUSION
As you can see not a lot of forms are needed in the general management of the uncomplicated admitted patient. By memorizing and becoming comfortable with six basic forms, you should be able to handle the majority of admissions and necessary documentation without great effort or angst. Most interventional radiology practices have other detailed order forms for chronic cases, such as thrombolysis, pain management (personal controlled anesthesia forms), heparin sliding scale, and others. These have not been addressed specifically because they are not directly related to patient admission and are used more for disease management.