Documenting in the Medical Record
- Every new patient will have a complete H&P documented by the next day
- Every patient you follow will have a progress note in the medical chart daily and ideally by noon
- Only vital signs and pertinent lab data may be cut and pasted into H&Ps and progress notes
- EMR templates and smart phrases will NOT be used
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.
You may optionally submit sample progress notes at the end of the clerkship. Please limit this to no more than 2 examples.