Last Updated 06/13/2018
- Progress notes explains the treatment plan AND the thinking behind that plan.
- A well-crafted summary line is useful both to the writer and the reader. In addition to age and gender:
- Surgical admission: hospital day, diagnosis, active issues.
- Postop admission: postop day, operation, indication, active issues.
- Trauma admission: post-injury day, bulleted list of injuries and management.
- Consultation: reason for consultation, primary service.
- Focus should be on the assessment and plan; emphasis should be on readability.
- . Maximum length should be 1-2 screens.
- Bulleted lists are helpful.
- NEVER use “COPY FORWARD”
- . Simply, “copy forward” is bad physicianship.
- It is an error-prone process: mistakes are propagated.
- It does not save time; it is more time-consuming to edit yesterday’s note than start fresh.
- To preserve summaries and details of the hospital course, please use the “Handoff” function in EPIC.
- Avoid lists of auto-populated data.
- . There is no need to auto-populate medications, vitals, labs, etc., as nobody is going to use your note as a reference for clinical data.
- Because auto-populated data is rarely reviewed as it is written, auto-populate can lead to the “writing” of erroneous or problematic data that you have overlooked, e.g., a critical or spurious lab value, or a missed radiographic finding.
- Do not delete or ignore sections required for hospital compliance, e.g., DVT prophylaxis, lines, skin assessment, reason for hospitalization, etc.
- Language is important: be specific. Write down diagnoses whenever possible.
HISTORY AND PHYSICAL
- The initial H&P is the best opportunity write an accurate story about the patient’s illness.
- Do not ignore the family history.
- Do not ignore the social history: you should address occupation/employment (premorbid functional status), family situation (disposition), and substance history (anesthesia risk).
- The “Procedure in Detail” should focus on what you did, and why you did it.
- Include details about DVT prophylaxis, antibiotics, and the operative time-out.