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
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.
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 &
A sample note -
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
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
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
1. 65% BSA burn w/inhalation injury
S/P exc & grafting doing well
Plan: Will wean from vent. today. Try to
Cont local wound care
D/C Vanco when extubated
Will increase feeds
Will increase propranolol
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 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 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:
Surgeons and Assistants:
Preoperative diagnosis: (i.e., big bad burn)
Findings: (if pertinent)
Operation: (name of procedure - be detailed)
Amount of skin grafted: (cm²)
Estimated blood loss:
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.
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.
Complications: (e.g. infections, graft loss)
Condition on discharge:
The dictated discharge summary should also
include history, exam, labs, hospital course and disposition, including
diet, activity and medications.
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.