Basics of Note Writing
The style and speed in which you write notes for patients will vary - it does for everyone. Everyone has their own personal touch on how they write notes, and you will get lots of advice on notewriting throughout your training. The most important thing is to not take shortcuts and develop your skill to improve your speed, efficiency and wording.
- Setting up EPIC: After your initial EPIC training, you should get with another APP to help give you access to the premade templates below and make your signature.
- The GLA Template: Instead of writing our notes from scratch, we have a template that we use to stay consistent within providers/the group. On EPIC there are things called dotphrases where you type a period followed by a word in order to bring up these templates in a blank note.
- For ICU progress notes: ".glaicunote"
- For ICU consult notes: ".glaconsult"
- For CVL consult notes: ".glacvlconsult"
- For H&P notes on admission: ".glahistory"
- The most important thing of a note is - what are you going to do?
- At the end of the note under the Assessment/plan you should have at least three problems.
- At the end of every note you must CHARGE for your time. You do this by stating the charge in your note then actually clicking the charge button on EPIC. We have two charges we commonly use; critical care time and V3. Ask a veteran APP to explain this to you.
Writing an Assessment/Plan -
There are many ways to do this, but in general ALWAYS keep the following format:
- Etiology of problem
- Data supporting problem
- What are you going to do about it??
Acute Kidney Injury
- Etio: suspect prerenal 2/2 intravascular depletion
- Baseline creatinine 1, now elevated to 2.4
- Trend daily BMP, monitor UOP
- Consider renal US/nephro consult if worsens