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Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern.
Wei, Miao; Salgado, Efrain; Girard, Christine E; Santoro, Jonathan D; Lepore, Natasha.
Afiliación
  • Wei M; Internal Medicine, Cleveland Clinic Florida, Weston, Florida, USA.
  • Salgado E; Department of Neurology, Cleveland Clinic Florida, Weston, Florida, USA.
  • Girard CE; Department of Internal Medicine, Cleveland Clinic Florida, Weston, Florida, USA.
  • Santoro JD; Department of Neurology, University of Southern California, Los Angeles, California, USA.
  • Lepore N; Department of Radiology, University of Southern California, Los Angeles, California, USA.
Postgrad Med J ; 99(1171): 492-497, 2023 Jun 08.
Article en En | MEDLINE | ID: mdl-37294720
A physician's progress note is an essential piece of documentation regarding key events and the daily status of patients during their hospital stay. It serves not only as a communication tool between care team members, but also chronicles clinical status and pertinent updates to their medical care. Despite the importance of these documents, little literature exists on how to help residents to improve the quality of their daily progress notes. A narrative literature review of English language literature was performed and summated to provide recommendations on how to write an inpatient progress note more accurately and efficiently. In addition, the authors will also introduce a method to build a personal template with the goal of extracting relevant data automatically to reduce clicks for an inpatient progress note in the electronic medical record system.
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Texto completo: 1 Colección: 01-internacional Banco de datos: MEDLINE Asunto principal: Documentación / Pacientes Internos Tipo de estudio: Guideline Límite: Humans Idioma: En Revista: Postgrad Med J Año: 2023 Tipo del documento: Article País de afiliación: Estados Unidos

Texto completo: 1 Colección: 01-internacional Banco de datos: MEDLINE Asunto principal: Documentación / Pacientes Internos Tipo de estudio: Guideline Límite: Humans Idioma: En Revista: Postgrad Med J Año: 2023 Tipo del documento: Article País de afiliación: Estados Unidos