Harbor:Attending documentation

Overview

  • For all patients physically present in the department at change of shift (whether dispositioned or not) attendings should write and save one note (ED Attending Note), to be modified by the subsequent attending as needed for that episode of care. This note will include all attending documentation, including language regarding admission or change in status (observation or CORE). Attendings should make sure notes are completed prior to leaving the ED.
  • For patients seen only on your shift and that depart prior to the end of your shift: attendings have the option of modifying the residents note with an attending note OR completing a separate attending note. These notes can be completed within the 72 hour documentation completion timeline.
  • Interqual documentation will always be in a separate note, called "Interqual Override Note".

(T. Horezcko 7/7/15, Clarification 9/28/15, Dir OPS 9/28/15)

Minimum Content for Attending Notes

  • For patients ADMITTED or PLACED ON OBSERVATION OR CORE STATUS
    • Acute problem list (should justify the need for Admission/OBS/CORE)
    • Brief history supporting admission/OBS/CORE required only if problem list does not support your decision
    • Care Level (ICU/PCU/Tele/Ward, etc.)
    • Admitting Service

(Note should be placed prior to or as close to the time of the order for this activity (Admission/OBS/CORE) as possible.)

  • For patients STILL ON THE TRACKING BOARD at time of sign out (INCLUDING discharged patients still on board)
    • Acute problem list
    • Brief plan, if known
    • Disposition, if already determined or discussed with housestaff, that the attending would feel comfortable with without further involvement of the oncoming attending.
  • For all DISCHARGED patients (NOT left over on TRACKING BOARD - but departed ED during your shift)
    • Documentation is at the discretion of the attending. No specific or minimum documentation (other than a signature on the housestaff H&P.) is required. If documentation is desired, it can be made either as an addendum to the H&P or in a separate Attending Note

(Faculty Agreement 11/16)

See Also

Authors:

Ross Donaldson