We need you! Join our contributor community and become a WikEM editor through our open and transparent promotion process.
Difference between revisions of "Template:Resident Documentation"
From WikEM
(Create template) |
(Add NP supervision and phrase for indepently evaluated patients) |
||
| Line 1: | Line 1: | ||
===Resident Documentation=== | ===Resident Documentation=== | ||
| − | *1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. | + | *1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. Attending". |
| − | *2. When working with an intern, its always important that you independently confirm the key elements of the intern's history and physical. When documenting involvement, residents should: | + | *2. If you are a senior seeing and discharging a patient independently and discharge without presenting the patient, please use the phrase "Seen under supervision of Dr. Attending". |
| + | *3. When working with an intern or NP, its always important that you independently confirm the key elements of the intern or NP's history and physical. When documenting involvement, residents should: | ||
**a) Have the intern submit the chart to you for SIGNATURE, not just REVIEW | **a) Have the intern submit the chart to you for SIGNATURE, not just REVIEW | ||
**b) Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM | **b) Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM | ||
**c) Your ADDENDUM must at a minimum state what you did independently. | **c) Your ADDENDUM must at a minimum state what you did independently. | ||
**d) Remember, medical student patients require a completely separate and complete H & P. | **d) Remember, medical student patients require a completely separate and complete H & P. | ||
| − | * | + | *4. Try not to put raw data into your note that exists elsewhere in the EHR. Instead, you should comment on your interpretation of that data. |
| − | * | + | *5. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature. |
Latest revision as of 01:27, 7 February 2017
Resident Documentation
- 1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. Attending".
- 2. If you are a senior seeing and discharging a patient independently and discharge without presenting the patient, please use the phrase "Seen under supervision of Dr. Attending".
- 3. When working with an intern or NP, its always important that you independently confirm the key elements of the intern or NP's history and physical. When documenting involvement, residents should:
- a) Have the intern submit the chart to you for SIGNATURE, not just REVIEW
- b) Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM
- c) Your ADDENDUM must at a minimum state what you did independently.
- d) Remember, medical student patients require a completely separate and complete H & P.
- 4. Try not to put raw data into your note that exists elsewhere in the EHR. Instead, you should comment on your interpretation of that data.
- 5. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.
