Harbor:Resident documentation - Revision history

Rossdonaldson1: Text replacement - "Harbor:Operations manual" to "Harbor:Main"

2019-01-31T06:46:09Z

Text replacement - "Harbor:Operations manual" to "Harbor:Main"

← Older revision		Revision as of 06:46, 31 January 2019
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	==See Also==		==See Also==
	*[[Harbor:~~Operations manual~~]]		*[[Harbor:Main]]

	==References==		==References==

Rossdonaldson1 at 22:40, 7 January 2019

2019-01-07T22:40:18Z

← Older revision		Revision as of 22:40, 7 January 2019
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	#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.		#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.
	#All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.		#All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.


			==See Also==
			*[[Harbor:Operations manual]]

			==References==
			<references/>

			[[Category:Admin]]

Rossdonaldson1: Created page with "#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". #If you are a senior seeing..."

2019-01-07T22:39:58Z

Created page with "#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". #If you are a senior seeing..."

New page

#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".
#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".
#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:
#*Have the intern submit the chart to you for SIGNATURE, not just REVIEW
#*Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM
#*Your ADDENDUM must at a minimum state what you did independently.
#*Remember, medical student patients require a completely separate and complete H & P.
#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.
#All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.