Residents are REQUIRED to write notes on every patient on their service for every shift. THERE ARE NO EXCEPTIONS TO THIS.

It is VITAL that notes are dated for the date of service. This gets more confusing at night due to the day change but basically boils down to this- patients who are on your service at the start of your shift need to have a note dated for the start of your shift. Patients who arrive after midnight will have an H&P note dated for the date that they were admitted. For example-

Start of PM Shift Patient List Jan 1 (Note date)                     Admission @ 0200 Jan 2

Patient A  (Jan 1)

Patient B  (Jan 1)

Patient C (Jan 2)

The easiest way to ensure that there is no problem is to immediately begin notes on all of your patients as soon as your shift starts. For any admissions that come in, immediately start a note so that it matches the date that the patient was admitted. Notes do not have to be filed/completed on the same day, just by the end of the shift. For example, a note started on a patient admitted at 2330 on Jan 1 must show the date of service to be Jan 1, but can be finished by end of shift at 0600 on Jan 2.

If you have any questions about your notes, please ask your attending or fellow.