– Admission: H&P note
Admission order: Doctors’ menu. Medical Service. Admit/Transfer to Medicine. (Provider: senior resident on the team)
– Progress note: “Medicine Physician Progress Note”
1.”Physician Discharge Note” – have to complete before the patient can leave the hospital
- Fill out note. Tell your attending that it is filled out and ready for them to sign. Then you place the D/C order after the attending has signed the note.
2. Discharge Summary: Click D/C Summary tab along bottom of the screen. Scroll down to 3rd option: “D/C Summary”
- If patient is going home, then this note can be filled out after the patient leaves the hospital.
- If the patient is going to a nursing home or to the CLC, this note has to be filled out, printed, and hand signed and given to the SW to fax to receiving location prior to discharge.
– Transferring patient – to/from: ICU/PCU/CG or E2 (psych):
- Must fill out a “Transfer Summary Note”
– Consults: “gen internal medicine consult note”
– How to DELETE A NOTE:
1. Assign cosigner: Mullins-Allen, Angela.
2. Addendum: Please delete this note that was signed in error.