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Template:Resident Documentation
From WikEM
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.
