Documenting in the Medical Record

Expectations

  1. Every new patient will have a complete H&P documented by the next day
  2. Every patient you follow will have a progress note in the medical chart daily and ideally by noon
  3. Only vital signs and pertinent lab data may be cut and pasted into H&Ps and progress notes
  4. EMR templates and smart phrases will NOT be used

Teaching Activities

Written instructions and examples are provided. Any note you write may be given to a peer, team member, and/or your IM coach for feedback.

Assessment