Harbor:Resident documentation

  1. All charts should mention which attending you formulated the plan with in the text of the H&P. For example: "Case discussed with Dr. Attending".
  2. If you are a senior seeing and discharging a patient independently and discharge without presenting the patient, please use the phrase "Seen under supervision of Dr. Attending".
  3. When working with an intern or NP, its always important that you independently confirm the key elements of the intern or NP's history and physical. When documenting involvement, residents should:
    • Have the intern submit the chart to you for SIGNATURE, not just REVIEW
    • Do not insert your note into the body of the intern's note, place it at the end as an ADDENDUM
    • Your ADDENDUM must at a minimum state what you did independently.
    • Remember, medical student patients require a completely separate and complete H & P.
  4. Try not to put raw data into your note that exists elsewhere in the EHR. Instead, you should comment on your interpretation of that data.
  5. All acceptance ("sign out") notes should at a minimum contain an acute problem list, Please send these notes to your attending for signature.

See Also