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Documentation Expectations

Page history last edited by Lenny 2 years, 9 months ago


 

General Guidelines

If you see a patient and make a medical decision, this should be documented in Powerchart.

Each note should be accurate and cut and paste without significant revision is not appropriate.

Documentation should be prompt, concise, and effective for its purpose.

 

Admission

A history and physical must be done on every admission.  A medicine resident accept note should be entered by the resident with the admission orders on all admissions done with an intern.  More information can be found here.

 

Interim Summaries/Transfers

MD Transfer

Interim summaries should be done when primary MD is transferring off service for all patients that have been on a team for greater than 4 days. 

Service Transfer

Interim summaries must be done for all transfers between services.  These must be done in a hospital course problem list format, interim summaries from MICU to floor should not be done system based.  For an example of an ICU transfer note that is not optimal click here: Poor MICU Transfer Note

 

Cross Cover

Inpatient progress notes should be entered by a cross cover physician if any changes were made to management or any new developments arose.

 

Discharge Summaries

Discharge summaries must be done on all discharges the same day of discharge.  The discharge template is available here.  A daily note is not necessary on the day of discharge.

 

Daily Progress Notes

A daily progress note should be entered for all inpatients everyday.  These must be completed every day (preferably before noon) to allow nursing and consultant review of current information.  If new developments arise, an addendum should be added to the completed note.  A daily note is not necessary on the day of discharge.

 

Phase 2 Student Notes

  1. Phase 2 students will write daily progress notes under their own name in Powerchart
  2. Students will forward their notes to the resident (or directly to the attedning if the resident is off)
  3. The resident will write a complete note (essentially a full progress note) that is thorough enough to meet billing requirments and provide all necessary information about patient care to anyone who accesses it
  4. Only the following items from student notes may be referenced in the addendum: PMH, SH, FH ROS.
  5. All abnormal labs/studies must be addressed in the resident's addendum 
  6. The residnet/attending should not edit the student note unless there a gross errors
  7. students should recieve feedback on their notes daily by at least 1 memeber of the team
  8. Phase 2 students do not dictate discharge summaries

 

 

Electronic Notes

All documentation should be entered in Powerchart, written notes are not acceptable for documentation.  Notes should be entered in standard format approved for the document type.  Use of cut and paste should be monitored closely and each provider should ensure that documentation being entered is accurate and updated.

 

ER Admission Request

If you are called by the ER to evaluate a patient for admission to a medicine service, you should leave a note if you decide not to take the patient.  This is especially true to MICU.

 

Consultation

Initial consultation and all follow up consults should be entered under inpatient medicine consults.  A note should be entered everyday that a patient is being followed, and an official sign off and documentation should occur before stopping daily notes.

 

Procedure

All procedures must be documented with the standard documentation.  Templates here.

 

Code Status Note

A code status note should be entered on every patient admitted to the hospital if one does not exist.  If it does exist, you should confirm that it is accurate and reference it.

 

Comments (1)

Kendall Rogers said

at 3:26 pm on Feb 4, 2010

I think a general guideline should be Either do not do any abbreviations or if so, do only standard universally acceptable abbreviations. If you are not sure, do not abbreviate. Some example of unacceptable abbreviations that we have seen used: bf for boyfriend, prob for probably, dced for discontinued, and many others.

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