UCLA Resident Education System
On Campus Access: #30 or 42001
Off Campus Access: (310) 794-2001
Dictation services number 55831
Westwood Worktypes:
1 Discharge/Death/Transfer Summary
11 Addendum to Discharge/ Death/ Transfer Summary
3 Inpatient Procedure Note
33 Outpatient Procedure Note
4 Inpatient Consultation
44 Outpatient Consultation
5 Inpatient H&P
55 Outpatient H&P
6 Test Results
7 Inpatient Progress Note
77 Outpatient Progress Note
8 Letter
Keypad Functions:
1 Pause
2 Record
3 Five Second Rewind
44 Fast Forward to End
5 Disconnect
6 Five Second Forward
77 Rewind to Start
8 Dictate Next Report
0 Play Current Report
* Mark as Stat
# Clear Stat
Discharge/Death Summary Format
Full Name of Dictator (spell)
Patient Name (spell)
MRN
Date of Admission
Date of Discharge/Death
Attending of Record
Residents
Reason for Admission
PMH
PSH
FH
SH
ROS
Significant PE
Significant Lab Data
Hospital Course
Complications
Transfusions
Discharge Meds
Operations and Procedures Performed
Discharge/Final Diagnoses (no abbreviations)
Condition on Discharge
Disposition of Patient
Follow-Up
Discharge Instructions
Diet and Activity Level
Cc: Full Names/Addresses
Discharge Note for Admission of 2 Calendar Days or Less (Dictated or written. Patient admitted on 4/22 at 1 am, discharged 4/24 at 11 pm = 2 calendar days and you may use this brief discharge note.)
No abbreviations may be used!
Date of Admission
Date of Discharge
Discharge Diagnosis
Attending
Residents
Operations or Procedures
Discharge Meds
Follow-Up: Physician, Time, Location
Sign, Date, and Time Noted
DISCHARGE SUMMARY at VA
These should follow similar format as above. Many residents have a saved template.
At the VA, a patient information form must also be completed.
DISCHARGE SUMMARY for UCLA Stroke Service
Service
Service Name, Attending, Residents
Admission Date:
Discharge Date:
Discharge Diagnoses:
Consults:
Admission HPI:
- Up to and including the Physical Exam on admission.
- Please include initial NIHSS:
- Please include pre-stroke modified Rankin Scale:
Hospital course:
- Including procedures and complications.
Exam on Discharge:
- General exam:
- Neurologic exam:
- NIHSS on day of discharge:
- Modified Rankin Scale on day of discharge:
- Ambulation status: (please choose one) independent ambulation, ambulation with assistance, or unable to ambulate
Pertinent laboratory values including, but not limited to:
- A1C
- Fasting Lipid Panel
- hsCRP
- ESR
- Homocysteine
- Other significant labs
Diagnostic studies:
- Including radiologic tests, EKG, TTE/TEE:
- Neuroimaging tests
Assessment
including Likely Stroke Mechanism(s): (Large artery athero, small vessel disease, cardioembolic, other/specify)
Plan/Recommendations:
- Active neurological and medical problems on discharge.
Disposition:
- Pt was discharged to_______.
Discharge Medications:
* Note: if discharged on no antithrombotic agent or statin, please state why.
* Note: if atrial fibrillation and not discharged on anticoagulation, please state why
Follow-Up:
Including pending labs, if any.
Patient care was discussed with Dr. __________, Attending physician, who agrees with above plan. Patient and caregiver stroke education was performed. Smoking cessation counseling (if applicable) was performed.
BILLING REQUIREMENTS FOR NOTES
Brent Fogel, MD, PhD. Reviewed by Mark Nuwer, MD., 6/08
This will meet Level 5 criteria unless indicated.
HISTORY
Name of Referring Physician (Attending): (required if consult)
CC: (always required)
HPI: (minimum 4 items [location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms] or the status of 3 chronic or inactive problems)
PMH/FH/SH: (list minimum 2 of 3 for return patient, list all 3 for new)
ROS: (list minimum 10 of 14 for a Level 5 or 2 of 14 for a Level 4) This can be satisfied by questionnaire recorded by the patient if the physician documented that he or she reviewed the information.
PHYSICAL EXAMINATION
(All 23 items are required for new patient; none are required for a return visit)
1. General appearance
2. Vital signs (at least three)
3. Cardiovascular (minimum 1 of 3; heart auscultation, carotid auscultation, or peripheral pulses)
4. Attention span and concentration
5. Orientation to time, place, and person
6. Language (i.e. naming, fluency, repetition, comprehension)
7. Fund of knowledge (e.g. awareness of current events, vocabulary)
8. Recent and remote memory
9. Ophthalmoscopic examination
10. CN 2
11. CN 3,4,6
12. CN 5
13. CN 7
14. CN 8
15. CN 9
16. CN 11
17. CN 12
18. Muscle strength
19. Muscle tone
20. Coordination
21. Deep tendon reflexes
22. Sensation
23. Gait and station
MEDICAL DECISION MAKING (Required for both new and return patient)
1. Number of diagnosis
- List all diagnoses addressed (> 3 if possible). Include medication side-effects.
2. Complexity
- List all differential diagnoses for any uncertainties. Explicitly state all severe ones such as tumor, seizure, stroke, etc.
3. Risk of Morbidity
- Make a statement regarding the risks of the illnesses.
4. State “Discussed plan with patient, who agrees”
5. Send a copy to the referring physician
Other Useful Information
COUNSELLING
"More than half of this ____ minute visit was spent counseling the patient on _______."
(If this statement is utilized, note can be free-form without any other requirements. However, this only applies to attending notes and attending’s time.)
MEDICAL STUDENT NOTES
ONLY ROS and PMH can be referenced (e.g. “see medical student note”) to count for billing purposes
DEFINITIONS
Established clinic patient = last visit < 3 years
New clinic patient = last visit > 3 years
Consult = a request for an opinion
If self-referred then treat as a new patient
INSURANCE CODES
Axx = PPO
Cxx = California Children's Service
Fxx = Medicare (FMC) +/- HMO (FMH)
Gxx = Grants
Ixx = Private Insurance
Nxx/Mxx/Uxx = HMOs
PAY = Self-pay
Sxx = MediCal
F99 = Other
Zxx/Xxx/Yxx/Qxx = Other agreements
For more information or examples on coding, refer to Practice section of AAN website (https://www.aan.com/go/practice/coding/evaluation).
University of California © UC Regents
Powered by the
Mobile Web Framework