Tentative Daily Schedule for inpatient month
-5:30: Get to the hospital early e.g. 5:30. You can get there later e.g. 6:00am if you know you’ll be done by 7:00am.
-5:30-7:00am: Examine all your patients, talk to nurses, look at labs, and think plans, and begin your progress notes before 7:00am.
-7:00 to 7:30: Report -run through the list.
-7:30 to 9:00am: Resident protected time to complete notes.
-9:00 to 12:00pm: Rounds with attending.
-12:00 to 1:30 Noon Conference. Grab food on the way.
-2:00pm to 3:00 Meet again and review list.
-Evening – Didactic Process
Admitting a Patient in Cerner PowerChart
Tips for Progress Notes, Discharge Summaries, and Organization
Discharges: Start working on the discharge summary, med reconciliation before the discharge day even happens. On the morning of d/c, it would be very easy to do it. Many hospitals run like hotels, there is a prefered check-in time and check out time. In our facility, all discharges must be done before 11:00am. That means the discharge order and medication reconciliation must be done before 11:00am. Ideally, the discharge summary should be done before 11:00am as well (between 7:30 to 9:30am –the resident protect time for notes). However, the summary may be done later.
** On the day a patient is being discharged, you don’t need to write a progress note plus a discharge summary. You only need to write the discharge summary and it will count as the documentation for that day.
Disposition: Every progress note should have a disposition. Start thinking of next steps.
Med Reconciliation: Reconcile home meds upon admision and then every day if patient is not on all home meds. If patient is not on some home medications, have a section at the bottom of your assessment and plan that says which home medications are being held and why they are being held. Say if the hold is temporary or they are being discontinued permanently so that the patient won’t be going home on them. If there are any meds being temporary held, reevaluate daily and restart them if appropriate.
Progress Notes: Get your progress notes done as you go and as early as possible, even if some labs are still pending. You can always do an addendum as new information becomes available. See the computer as a paper chart. If you were documenting in there, you will write updates to progress notes throughout the day as new information became available. You would only write one SOAP note in the morning, say at 7:00am. If at 10:00am, the patient’s status changed, you would write an addendum with the status change and plan.
Many attending docs at our facility type their progress notes. The same is true for all our residents. I like to write my progress notes with the discharge summary in mind. For example, I include a section in there where I list all the consultants and another where I list all the procedures done. This is not difficult to do because you can copy your progress note from the previous day and simply edit it. By the time it comes to discharge, it’s simply copying and pasting a lot of material from my progress note and completing the rest without much effort.