NOTHING should be posted on social media regarding professional identity, patients, or workplace
Beneficence
Acting in the patient's best interest
Non-Maleficence
The principle of doing no harm
Autonomy
Obligation to respect patients as individuals and honor their preference in medical care (informed
consent, confidentiality)
Justice
Treating persons fairly and equitably
Clinical Notes Comparison
(1) Convey information for future selves, other providers, and patients (2) Billing (3) Legal considerations
H&P
Hospital admission note, initial visit at outpatient PCP
SOAP
Progress note, most notes outpatient
Admission Orders
Include in the plan section of SOAP using the mnemonic ADC VANDALISM
Discharge Summary Note
Includes discharge diagnoses, medications, hospital course, disposition, follow-up
Transfer of Care Note
Documenting transfer from ICU to hospitalist team
Procedure Note
, Includes date & time, type of procedure, pre-op dx, post-op dx, consent, providers present, anesthesia,
labs/studies sent, blood loss, complications, disposition
ER Note
Includes ER course, medical decision making, disposition, follow-up
Psychiatric Evaluation
Involves elements such as CC, HPI, Past Psych Hx, Med Hx, Sub Use, ROS, Fam Hx, Psych Hx, Social Hx,
Mental Status Exam, Risk, Labs & studies, problem list, assessment, plan
Mental Status Exam
Assessment of general appearance + behavior, speech, affect, mood, thought process, thought content,
cognition
Sustained emotional makeup of a person (ex: happy, angry, elated, euphoric)
Thought Process
How organized thoughts appear, including logical, circumstantial, tangential, flight of ideas, loose
associations
Thought Content
Includes delusions, hallucinations, obsessions, thought insertion, ideas of reference
Safety
Assessment of suicidal ideation, homicidal ideation, self-injurious ideas, impulses, plans
Cognition
Assessment of level of consciousness, orientation, attention & concentration, memory, calculation,
abstraction, judgment, insight
Case 1
Detailed case presentation with mental status exam findings
Duty Hour Policy
Educational work hours are a minimum of 40 hrs/week and no more than 80 hr/wk averaged over a 4 wk
period
Logging Duty Hours
Process of logging hours on eValue, including supervisor's name, rotation, start/end time, comments
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