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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: we have templates that are designed to capture the appropriate billing requirements for each patient billing codes. We utilize templates to ensure the information is consistent and accurate 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 H&P notes on admission: ".glahistory"

  • ASSESSMENT/PLAN: The most important thing of a note is - Documenting how you are progressing the patient through an accurate assessment, plan formulation and execution.

  • BILLING: 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.

Writing an Assessment/Plan -

We use a problem based approach:

1. PROBLEM ( diagnosis, as specific as possible)
- Etiology of diagnosis
- interpreted data to support/defend diagnosis (if applicable)
-previous interventions ( if applicable)
- YOUR INTERVENTIONS/PLAN

Example:

Submassive PTE
-in the setting of recent gastric cancer diagnosis & immobility
-evidence of RV strain on echo, elevated cardiac biomarkers
-s/p EKOS on 5/22
-hep gtt, transition to Eliquis today

Example of what not to do:

VTE
-BNP 150, troponin 2, RVSP 56 ( what does this mean)
-CTA with pulmonary embolism
-s/p EKOS

  • comments: is it provoked or not? this will determine treatment length, need to identify etiology. what do those numbers mean clinically ( really needing to identify there is RV strain making this a submassive pe), major procedures should have a date tied to them, and there is no active plan for today