Guidelines for orders and notes
You will ordinarily write the orders and notes for all of your patients.

Guidelines:

1. Review your interpretations with your supervising physician before writing them down.
   
   
2. Make absolutely sure that an order is right before you write it down. Check and double-check.
   
   
3. Make sure that all orders and notes are countersigned by your supervising physician.
   
   
4. For computer records and orders, you MUST log-on using your own name and identification code. You are NOT permitted to enter anyone else's name or identification code. THIS IS IMPORTANT!
   
   
5. Avoid contentious or critical remarks in the patient chart.
   
   
6. Highlight major findings (e.g., guaiac positive stool, CT scan showing liver mass, new hemiplegia).
   
   
7. Enter important patient data as soon as it becomes available.
   
   
8. Whenever you evaluate a patient, you should document the event in the medical record. This pertains both to daily progress notes, and to any other interaction you have with a patient.
   
   
9. In the era of the electronic medical record, it is tempting to copy Monday’s note, edit it, and paste it into Tuesday’s note. THIS PRACTICE IS NOT RECOMMENDED. The risk is that erroneous or obsolete information is copied and not updated. Further, it discourages original thought.
   
   
10. The chart is a permanent legal record.
    
    

Accessing patient records
All medical records are accessed on a "need-to-know" basis. That is, you may open a patient's record, be it on paper or be it electronic, ONLY

• if you are personally involved in the patient's care.
• if you are preparing a case for a specific educational purpose

You may not open a patient record for any other reason. The hospital monitors access to patient records and may take disciplinary action if these guidelines are violated.

When opening an electronic record, you MUST use your own computer code and password. You must NOT access the record using another person's code or password. As soon as you are done examining the record, you must close the record and sign out.

DO NOT disclose your computer code or password to anyone else.

Sample admission orders
See Essential Skills in Clinical Medicine

Sample admission note
See Essential Skills in Clinical Medicine

Sample progress note
See Essential Skills in Clinical Medicine