H & P

o   HPI

o   Chief Complaint – in patient’s words EG: “Chest Pain” not “Angina Pectoris”

o   Click PCP – if Unknown delete text – leave it blank

o   HPI

§  At least 4 components of OPQRST for the chief complaint (Pain, shortness of breath, dysphagia, …)

§  OR 3 past medical problems and their condition (EG: Well controlled DM2 or Poorly controlled HTN…)

§  Should include story of patient’s presentation up to and including ER include all prior tests, therapies that have to do with the present illness.

§  IF any history obtained NOT from the patient EG: Family, records, ER doc write that “part of this history was obtained from {source}.”

o   HX

o   Past Medical History (List)

o   Past Surgical History (List)

o   Social History – should include at least 3 components (Alcohol, tobacco, drugs)

o   Past Family History (update it! If it’s not in there) DO NOT LEAVE BLANK

§  If none or unknown: “Discussed family history with patient, patient does not have (or does not know) of any family history”


o   ALLERGIES – Make sure this is filled in with NKDA if it’s blank and no allergies

o   ROS

o   10 systems with at least 2 components in each system

o   PE


o   PE with at least 10 systems, at least 2 components per system

o   Results

§  Click Findings and Data, if nothing populates summarize outside records here

§  Click radiology data

§  Under radiology Data – Free text:

·      IF Tele: “I personally reviewed patient’s telemetry strips and they show {result}”

o   Can be ER telemetry

·      IF EKG: “I Personally reviewed patient’s EKG and it shows {result}”

·      IF CXR: “I personally reviewed patient’s CXR and it shows {result}, final read per radiologist

o   ASSESSMENTS: (At least 4 items)

# Each assessment (especially the top 4) should include

1)    An accurate billable assessment: EG: Acute Gallstone Pancreatitis (not “Pancreatitis” or “LUQ Pain”)

2)    Then Intelligent Differentials with reasoning: “Differentials include Alcoholic pancreatitis however patient states does not drink alcohol and serum alcohol level is normal, Medication induced or autoimmune pancreatitis however given that the RUQ US shows biliary ductal dilatation and alk phos is elevated favor gallstone.”

3)    An ASSESSMENT (not raw data) of any pertinent finding that supports the assessment: EG: “CT scan showing no necrosis or pseudocyst formation”

# PRIORITIZE ASSESSMENTS by severity/acuity of illness

# DO NOT put any labs, med doses or values that will change daily

# Write ‘case discussed with Dr. {name} and he/she said what” – this can be a consultant, ER doctor, ER PA, whoever.

# Chronic and irrelevant conditions can be listed as “Issue – condition, meds at home”: EG: “HTN – well controlled on lisinopril”


o   PLAN: (At least 4 items)

- DO NOT use the word ‘continue’

- DO NOT state medication doses or sigs – just ‘atorvastatin’ (exception warfarin, insulin)

- DO write antibiotics + Start date and expected stop if known

- indicate which home medications are being held

- Then may write “remaining home medications reconciled as above”

FEN: Fluids, Electrolytes, Nutrition

PROPHY: DVT prophylaxis

CODE: “Full Code” or “DNR”

DISPO:  Chose one of these options

·      Place in Observation

·      Admit to inpatient due to…

o   high risk of decompensation 2/2 {explain}

§  SIRS, SEPSIS, any organ failure, patient’s general condition with multiple co-morbidities and advanced age

o   need for invasive procedure {what procedure?}

o   failure of outpatient therapy

o   >2 midnight expected length of stay 2/2 severity of patient’s illness