7. Notes on Notes
We recognize that note writing is tedious and time-consuming. However, documentation and effective communication is the cornerstone of good medical practice.
Notes should be timely, and most importantly, ACCURATE!
Attendings read all notes.
The quickest way to frustrate attendings is to write inaccurate notes.
- All notes written by residents/fellows must be linked to an attending to Co-sign. Please try to send SOW patient notes to the SOW, and trauma patient notes to the trauma attending of the day.
- All notes should have “Surgery” department selected at the top of the note.
- Do NOT copy/paste plans or daily events from previous day’s note. If you copy anything, you must make sure you edit it such that it is accurate.
- Don’t hesitate to frequently write “Addendums” on notes as plans change, or to write a new short note with additional information.
- Use note templates for all H&P, Consult, Trauma, and Daily Progress notes (see “Standard Note Templates and Ordersets”).
- All patients on whom a resident has written a note must be seen by that resident that day.
- If you are called to evaluate a patient with a concern, and especially if there is a change in status, it must be documented. See “Acute Event Note” in EPIC.
Key Points on Note Types:
- Progress Note: Use “no acute events” sparingly – it is rare that nothing subjective happens to patient, good or bad, for 24 hrs.
- Trauma Note
- All trauma notes should have a “Chief Complaint"
- Please be sure to fill out all fields in a Trauma H&P as this is used to populate the trauma registry.
- All should have “Chief Complaint / Reason for consult”
- HPI must include template components (severity, duration, etc.)
- Physical exam must include at least 10 systems
- Review of systems must include all listed systems
- Family and Social history must be included in all notes. Non-contributory is not acceptable documentation.
- Always include requesting physician in consult note