VA notes

VA notes:

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”

Discharge:

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 attendingĀ 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.

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