In general, interns are responsible for writing progress notes for their patients. Seniors will write notes for an intern who has the day off. Seniors are strongly encouraged to assist post-call interns with notes to prevent work hour violations. Teamwork is the key!
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Each patient needs a progress note written every day that they are hospitalized after the day of admission, including the day of discharge.
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The H&P written for a patient admitted after midnight counts as the note for that day. This is based on the time the patient arrived on the floor (not the ETC). To check this in EPIC go to patient encounter summary ⇒ Pt reports ‐ all links ⇒ patient information ⇒ ADT Events.
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Progress notes should include an Interval History, Review of Systems, Physical Exam, Laboratory Data, Radiology Data, Assessment, and Plan.
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The Assessment and Plan section should be organized in a problem-based format for ward patients, systems- based format for ICU patients.
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Consider adding a section in your plan to briefly outline patients’ diet, activity, GI/DVT prophylaxis, code status, and disposition.
