Standards of Documentation for Patients Admitted to the Medicine Program

From U of M Internal Medicine Wiki
Policies
Policy: Standards of Documentation for Patients Admitted to the Medicine Program
Policy Nr: Sec 03 - 04
Target Review Date: 2017-12-31
Main Stakeholder:

Standards

  1. A pertinent history and physical examination shall be documented in the medical record within 24 hours of admission by the Attending Physician or designate. The Attending Physician will countersign the designate’s entry or enter his/her own note on the record.
  2. The physician/designate accepting care of a patient in transfer from another service should write a chart note within 24 hours. The Attending Physician will countersign the designate’s note or enter his/her own note on the record. If a patient is transferred from one service to another, transfer of care must be written as a chart order.
  3. Patient transfers from physician to physician on the same service must have a chart review note written within 2 weeks.
  4. The Attending Physician will be responsible for ensuring thorough progress notes and assessments of periodic health status for long term (>30 days) patients at least once per month.
  5. Progress notes must be written daily on active teaching patients by the Attending Physician or designate. Communication must be legible. Nonteaching patients should have progress notes written no less than once per month.
  6. Attending physicians or designate shall be responsible for ensuring informed consent is given by all patients receiving medical interventions and procedures performed by the medical service, including blood and blood products. Verbal consent for blood products is to be written on the progress note or order sheet.
  7. In-patient prescription orders and out-patient prescriptions, written by undergraduate medical trainees, shall be co-signed by a physician who is licensed to practice in Manitoba.
  8. House staff working with a particular consultant who respond to consultations on behalf of the consultant, must have the consultant review the case within 24 hours (including weekends) and leave a written response.
  9. Advance Care Plan status should be documented in the progress notes or on the WRHA Advanced Care Plan form by the attending physician or house staff within 48 hours of admission. A change of status should be documented immediately. The patient or their surrogate must be informed about any change in status.

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