Documentation demands attention to detail. For a patient with abdominal pain, be sure to ask: How long has the patient experienced pain? Is it generalized or in a particular quadrant? Sharp or dull? And does it radiate? And jot down the answers.
“Try to use adjectives that would give specifics regarding the complaint,” says Mary Mulholland, MHA, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania’s department of medicine. She also suggests hospitalists find out which medications a patient is taking or has taken and indicate whether symptoms have improved or deteriorated. Here’s how Mulholland would document such a case:
Initial hospital admission, level of service:
83-year-old male admitted from the emergency room, complaining of intermittent crampy lower abdominal pain (severe at times), blood in stool and increased weakness for three weeks, worse when getting up or standing. Patient has decreased appetite and progressive shortness of breath. His review of systems is otherwise negative.
Past medical history: Coronary artery disease and hypertension
Family history: Mother with Type 2 diabetes
Social history: Quit smoking 20 years ago
Alert: Blood pressure (90/68), pulse (88), and respiratory (24)
ENT: Dry oral mucosa
Lymphatic: Palpable nodes—right auxilla and right inguinal areas
Cardio: Slight tachycardia, no murmurs, rubs or gallops
Abdomen: Slightly distended, tender on palpation
Skin: Slightly diaphoretic, no rashes or bruising
Neurologic: Cranial nerves intact, alert and conversant
Lab results: Blood in stool, hemoglobin (6.7), serum blood glucose (120), serum sodium (132), serum potassium (4.3), chest X-ray clear (my interpretation). Old records requested.
Assessment: Gastrointestional bleeding, tachycardia, and mild dehydration
Treatment plan: Check hemoglobin and hematocrit every six hours. Also check prothrombin time and partial prothrombin time. Repeat electrolytes in the morning. Order an X-ray of the lower gastrointestinal tract. Type and screen for 2 units of packed red blood cells, and transfuse pending repeat hemoglobin and hematocrit values. Infuse intravenous fluids at 80 cc per minute. Check electrocardiogram. Consult GI regarding endoscopy.