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Resident Orientation Manual

Produced by Galveston Shriners Burn Hospital and
The University of Texas Medical Branch Blocker Burn Unit.
Contributors:  Sally Abston MD, Patricia Blakeney PhD, Manubhai Desai MD,
Patricia Edgar RN, CIC,John P Heggers PhD, David N Herndon MD,
Marsha Hildreth RD, Ray J Nichols Jr. MD

 

PAPERWORK

   At the burn units, the medical records department has prepared a thorough manual with rules and regulations to help you keep the records straight.  It is primarily the responsibility of the residents to maintain complete and accurate medical records.  This should include a thorough history and physical including burn diagram, detailed operative dictations and notes, legible medical orders and daily progress notes.  This latter record keeping often falls to the intern.  All documentation should be completed within 24 hours of the event.

Documentation
   The rule is simple:  If you don't write it down, you don't do it.  A corollary should be if an order is written a progress note should document why.  Notes are not just for now, but to lend information years from now.  Document, document, document.  The medical students may write progress notes with daily review and co-signature of Fellow or Faculty.

History and Physicals
  
You have learned how to obtain a medical history and you have learned some physical assessment skills in medical school.  Be thorough.  In burned patients, a couple of points should be emphasized.  Patient evaluation should include an AMPLE history:  allergies, medications, pre-existing diseases, last meal, and events of the injury, including time, location and concomitant insults.  A history of loss of consciousness should be sought.  When, where and how did the accident occur?  With children, stories that do not match the injury are suspicious for child abuse.  What time did the burn occur?  What was the initial treatment, including any narcotics or sedation administered and resuscitation in an outlying center?  What is the immunization status, especially tetanus?  Where is the child from and what is the situation at home?  At the Shriners Burns Hospital, a written H & P along with a dictated H & P is required.  Completion of the Burn Diagram in an accurate fashion is an important part of the History & Physical exam.

A sample note -


  7/1/92      07:10      POD##      PBD #7
              Pt. seen and examined w/Dr. Herndon
              No acute events overnight.
              VS:  T  38  Tmax  39.6  (1900 yest)
              Resp:  Vent  IMV 4,  TV  300, PEEP
              5, FiO2  0.50
              Lungs clear except basilar crackles.
              ABG,s  7.36/32/190  (sat 99%)
              CXR OK - no change
  Cardiovasc:  P130-179  (144 now)  BP
              120/76 - 110/70  (120/74)  CVP 4
              On propranolol  80 mg  TID
              Heart RRR w/o m,r,g
              +2 lower leg edema - good pulses
  GI:       NGT residuals 20-60 ml
              BM's 120 ml  (formed)
 

             Feeds:  Milk + 25 mEq NaC11/L + lactulose = 120 cc/hr/NGT
 
             Abd.  soft, nontender, active BS

              Caloric needs 80% met last 24 hrs
  GU:      I/O 3800/1900  fluid needs = 3500 ml/d
              U.O. 1.44 ml/kg/hr (past 12 hrs)
              electrolytes 134/4.4/109/31  BUN 14,
              Cr 0.6,  BS 109,  Ca++nl,  Mg++nl
              Foley d#7  On lasix/spirolact
  Hem:    S/P 2 units blood yest  Hgb 9.1,
              Hct 28   WBC 18K   Plts no
              On EPO
  Wounds:  Cult's from 6/29   <100 Staph on L foot
              Wounds clean at dressing to FMC
              Donor sites OK     ABX Vanco day #5
  Neuro:  nl, adequaic pain mgmt w/drsg

  Impression:
              1.  65% BSA burn w/inhalation injury
                   S/P exc & grafting doing well
  Plan:     Will wean from vent. today.  Try to extubate
              Cont local wound care
              D/C Vanco when extubated
              Will increase feeds
              Will increase propranolol
 

Progress Notes
   Progress notes are written daily on all acute patients.  Notes should include the date, the time, vital statistics, examination findings (including wounds), pertinent tests and laboratory data, clinical assessment and plan, and the physician's signature.  Data should support the impression and plan.  If the case was seen of discussed with an attending, that should be documented as well.  Organization is individualized, but generally, notes can be interpreted more easily if a systems approach is used, clumping data under general headings.  A data collection sheet is available on the ward to help organize bedside presentation and progress notes.

Pre-Operative Notes
   Pre-operative notes should be written the night before each operation, reflecting the planned procedure, predicted blood loss (1 cc/cm² to be excised) and allograft skin needs.  Review of wound cultures and appropriate antibiotic coverage should also be ascertained.  Documentation that informed consent has been obtained from the patient and/or their legal representative should also be contained in these notes.

Operative Notes
   Operative notes should be completed by the same person that dictates the operative summary to assure consistency of information.  Since many of our patients return to the operating room multiple times, accurate descriptions should include:  donor sites, area and depth of excision, (tangential vs. facial), areas autografted, size of meshing, coverage with homograft or other dressings, levels of amputations, untoward events in surgery, and estimated blood loss.  Estimation of blood loss usually equals blood replacement if post-operative hemoglobin is acceptable.  The usual format for OP notes consists of:

Date:
Surgeons and Assistants:
Preoperative diagnosis:    (i.e.,  big bad burn)
Findings:    (if pertinent)
Postoperative diagnosis:
Operation:    (name of procedure - be detailed)
Donor sites:
Amount of skin grafted:    (cm²)
Estimated blood loss:
Fluids:
Urine output:
Complication:
Post-op status:
 

Clinic Notes
   Outpatient clinic is held Monday through Friday in the Surgery Clinic for the Blocker Burn Unit and on the 4th floor of Shriners Burns Hospital in the Clinic.  The Blocker Burn Unit also has a tubroom clinic for adult patients with open wounds.  Notes should be dated and briefly describe the patient including name, UH#, birth date, date of burn, size of burn, last operation, last visit to the clinic and previous identified problems.  The note should then detail current status, examination, impression, and an acute care or rehabilitation plan.  If the patient is a Workers' Compensation injury, make note of work status.  Planned follow-up visit is recorded.  All clinic notes are dictated.  If we all go to both clinics, everybody gets done earlier. Any procedures done in the tubroom or clinic (i.e. Biobrane) should be dictated as an operative note as well.

Discharge Notes
   These are the most frequently forgotten portion of the medical records.  Whomever does the dictated discharge summary should also write a discharge note in the chart before the patient leaves the ward.  Do this as a last day progress note.

Admission date:
Discharge date:
Admission diagnosis:
Discharge diagnosis:
Operations:
Complications:  (e.g. infections, graft loss)
Condition on discharge:
Follow-up plans:
 

The dictated discharge summary should also include history, exam, labs, hospital course and disposition, including diet, activity and medications.

Orders
   Orders are only 'orders' once they have been written and signed-off.  Nurses will often take verbal orders from physicians in an emergency, as a courtesy.  Hospital policy requires all verbal orders be signed within 24 hrs.  Students can not write orders on the medical chart.  All orders should be written legibly in black ink, dated and timed, and signed. Listen on rounds for faculty directions and follow-up to ensure optimal patient care.  Explanations for changes in the treatment plan should be clearly outlined in the progress notes.

 

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