McMaster University

McMaster University

Patient Care/Chart Keeping Expectations

Admissions

  • Write full admission orders (include MRP on-call, transfer care to ‘Team 1/Team 2’ in a.m.)
  • Ensure history & physical is documented on chart

Charting

  • Admission note should include complete history & physical, assessment & plan
  • Progress notes should be written daily on every patient
  • All complex patients admitted to the hospital and residing in the hospital for over a week should have a summary of interval progress documented every Thursday by the resident or assigned learner. This should consist of a brief update of events of the week, significant physical findings, investigation results, and care provided during the preceding week. This will facilitate the provision of care over the weekend as well as help keep the numerous sub-specialists involved with each such patient updated. Further this weekly summary will be a great help in dictating the final discharge summary.
  • Off-service notes (at the end of a month/rotation) are also helpful and expected.
  • All patient care meetings such as those conducted with parents or multispecialty meetings should be documented in the chart by the learner assigned to the case, with a summary of the discussion.

Patient Referrals

  • All referrals to sub-specialists will take place with the explicit consent and request of the attending rather than a direct referral from the resident to the sub-specialists. The referral request will specify the question for which subspecialty input is required. Parents need to be aware of the request for subspecialty consult, especially involving Mental Health / Adolescent Medicine. The urgency of the consult should be relayed to the sub-specialist being called. The MRP should be fully aware of the patient’s details, as should the Resident / Learner calling the sub-specialist.

Transferring patients

  • When transferring patients, please verbally notify the resident on the new service (staff to staff handover should also take place independently).
  • Transfer orders to general pediatrics, Level 2 Nursery are expected.
  • Dictate transfer summary and write brief transfer summary in chart.

Discharging patients

  • Dictate a discharge summary for every pediatric patient. This should include dates of admission/discharge, admission/discharge diagnosis, discharge medications, follow-up plans, brief history & physical, pertinent investigation results and summary of course in hospital. See templates for general peds, Level II nursery, NICU, etc.
  • Complete face sheet prior to patient leaving hospital – this will be faxed to family physician’s office at the time of discharge. Face sheet completion prior to discharge is the responsibility of the learner. The face-sheet will be completed in detail, at the time of discharge. Information on this will include salient course in hospital, diagnosis at discharge, and follow up plan.
  • Complete any prescriptions, CCAC requests and other forms prior to discharge.
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