Harbor:Resident Documentation - Revision history

Hacharya at 16:36, 29 August 2016

2016-08-29T16:36:57Z

← Older revision		Revision as of 16:36, 29 August 2016
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	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.

	3. 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.		3. 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.
			**However, do include "wet" radiology reads in your note, as they are not saved when the final read is placed

	4. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.		4. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.

	[[Category:Admin]]		[[Category:Admin]]

Rossdonaldson1: Rossdonaldson1 moved page Resident Documentation to Harbor:Resident Documentation

2016-04-28T13:17:40Z

Rossdonaldson1 moved page Resident Documentation to Harbor:Resident Documentation

← Older revision	Revision as of 13:17, 28 April 2016
(No difference)

Rossdonaldson1 at 13:17, 28 April 2016

2016-04-28T13:17:30Z

← Older revision		Revision as of 13:17, 28 April 2016
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	4. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.		4. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.

			[[Category:Admin]]

PetersonMike123 at 00:08, 26 February 2016

2016-02-26T00:08:08Z

← Older revision		Revision as of 00:08, 26 February 2016
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	===[[Harbor:~~AResident~~ Documentation\|Resident Documentation]]===		===[[Harbor: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. Peterson, ED Attending".		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. Peterson, ED Attending".

PetersonMike123: Create template

2016-02-26T00:04:42Z

Create template

← Older revision		Revision as of 00:04, 26 February 2016
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	[[Resident Documentation]]		===[[Harbor:AResident 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. Peterson, ED Attending".		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. Peterson, ED Attending".

PetersonMike123: Add page

2016-02-25T23:53:58Z

Add page

New page

[[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. Peterson, ED 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:

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.

3. 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.

4. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.