Expanded Patient Tracker Explained
Sticker:
Put the patient’s sticker here. You’ll have the name, account number (for dictating), and the MRN number (for looking the patient up in the system). Next to the sticker, keep the numbers that matter to you: the admit dictation number and the discharge dictation number (just in case you do the work and someone says you didn’t. Rather than re-dictating, you can just say BOOM! here’s the number). Finally, in this section list the consulting physicians – who is on the case with you? This matters most for the discharge summary. H&P Essentials:
This is the chart review you get from previous H&Ps if they exist, or the mandatory info you need from the patient. It’s the past medical, past surgical, social history, fam history, allergies, and medications. Notice the short-hand, abbreviations, and truncated medication names. Coreg 25’’ means “Carvedilol 25 mg po bid”. Breaking that down, coreg is shorter than Carvedilol (can use brands in the real world), oral is assumed unless written, and the ‘’ means bid. SO LONG AS YOU KNOW WHAT IT MEANS, THAT’S ALL THAT MATTERS. Also notice the white space. There are distinct columns between the headings. The CHF business sort of runs over into meds, but it very intentionally lines up the dosages of medications. The methotrexate (MTX) is weird, so it doesn’t really fit. But that’s ok - for the most part there are discrete columns. It’s crucial to make it look good with solid organization. The goal is to enable you to quickly identify and pull data from the page on the fly. Spacing and white space is important. Vitals and Physical:
This includes the vitals when you saw the patient in the ED. It can also include the original vitals and the change from original presentation to the time you see them. But, NO RANGES. This is going to be for the H&P. The physical isn’t all written out, you notice. Intentional - only the pertinent findings go here. You know what a normal exam is and how to dictate it; there’s no reason to write out said normal exam in your your tracker. Here we’re helping you hone in on what to talk about on subsequent days – since the JVD was there day 1, you should probably mention it on day 2 and day 3.
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First Day Labs:
These are the labs you have in the ED, when the ED calls you, and what you order while you’re there. They’re the labs that will make up your assessment on the H&P. Using the sticks are crucial to saving time. You may not be familiar with the sticks, so they’ve been included with the main download. Just like in the H&P Essentials, there is intentionally white space; the labs are discrete, separated, and exist in columns. Short hand is used. The radiology findings do NOT have the report; they have the essential interpretation. For complex radiographic findings, it’s best to print out the report and just read it. Critical One-Time Labs, Imaging and Procedures:
This is actually a section on your discharge summary; it’s where things that happen once go. They’re distinct from the daily labs. They will, of course, be a daily lab the first day they’re obtained, but they’re the big tests that people want to know about. They get their own section because you want to be able to refer to them quickly; if they were in the daily labs and vitals, they’d be lost. It’s already quite busy on that left page - it might get worse if you started putting major tests in there. When it’s time to dictate your discharge summary, you’ll have that section ready to go. Imaging, procedures, and microbiology go here. Meds:
Notice that the same shorthand as in the H&P essentials is used. Keep it just the name, hashmarks for the frequency, and the dose. Again, note the use of white space and aligning dosages to easily access the information visually. When this was first built, there was a lot of white space with three lines between each medication. As time passed, medications changed. You can see IV Lasix was stopped, then oral Lasix started. Plavix was started, stopped, then started again. Coumadin was changed from 5 to 10. IF YOU USE A PENCIL AN D ERASE THE MEDICATIONS YOU CAN AVOID THIS UGLY PEN BUSINESS
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Day Labs and Vitals:
You see the same pattern repeat itself day after day. CBC, BMP Coags. They’re lined up in a column, even as you go day to day. Day 3, we didn’t get a CBC, so the space is left to keep the CBCs aligned. Vitals are in a row just beneath the labs, with 24 hour ranges. Finally, you can (optionally) put notes to yourself. You’re presenting the patient; you know what’s going on. You admitted them. You have the one-liner in the “Sticker” section to remind you (and the team) who this is. You talked with them, touched them that morning. You know their story and the physical results. But what’s hard to remember is the data: the labs, vitals, and meds. So as you present, do the story from memory, and then look down to reference the vitals and labs. It’s ok to read off details rather than trying to remember them all. Super easy. DO NOT overcrowd this Day Labs and Vitals sections with notes for what you will say. DO NOT overcrowd this Day Labs and Vitals section with your To-Do list. Keep your To-Do list separate. Core Measures:
You usually get these on the day of admit. You should be dictating them for every patient - both admit and discharge. They’re tucked in the corner so there’s always room for them. It tells you how much space you have for your medications. Active Issues :
Because you’re presenting from the book, you know what their chronic medical problems are (that’s the PMHx on the right page). But the thing that has to be named in your assessment – what you’re actively managing - goes here as a reminder of what’s going on. This person came in with a CHF exacerbation. But then they developed renal failure. The CHF exacerbation isn’t over, so now there are two problems. Damn that’s complicated. But rather than saying, “ 71-year-old man with a past medical history of … ” you say, “71- year-old man with CHF exacerbation and now acute renal failure with oliguria, unknown cause. ” Logic:
Now everything is visible to you on one open-face book. It’s easy to present from it since you know the story and have the details written down in front of you. You won’t have to keep flipping pages to find that lab or printing progress notes to read from. And you can detect trends (did you notice the Hgb falling?). You can actually reconcile medications. You have what they’re taking on the left, what they were taking on the right. Comparing becomes possible. Most importantly, you can dictate - whether it’s the admit dictation (the right page) or the discharge dictation (the right page + the active issues). Oh ya, and if / when they bounce back you’ll already have everything you need written here. Blamo
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