Charting

Remember the charting expectations which can be found here.

Click the My Note tab in Epic. At a minimum, every ED visit that involves an ED provider REQUIRES an ED Provider Note.  The majority practice at BIDMC is that the resident write the ED Provider Note, and the attending writes the ED Attestation Note. 

ED Provider Note 

At a minimum, every ED visit that involves an ED provider REQUIRES an ED Provider Note.   

If there is not a signed ED Provider Note, a deficiency will be sent to the InBasket of the first Attending and first Resident/APP who picked up the patient.    

At BIDMC/Needham, Residents SHOULD NOT send ED Provider notes to the attending for cosignature.    

At BIDMC/Needham, Medical students do not write notes.  They write the ED Handoff and the attending writes the ED Provider Note.    

ED Procedure Note 

This is where all procedures (ie- lacerations, intubations, sedation, POCUS) are documented using Epic’s PROCDOC.  When a resident documents a procedure, they MUST indicate an attending for attestation.    This will go to the attendings inbox to attest. The standard attestation will include the following necessary language: "I was physically present during all critical and key portions of the procedure and immediately available to furnish services during the entire procedure, in compliance with CMS regulations."

ED Observation Note 

There are templates for Intake, Daily and Obs Discharge notes.  most sites just do Daily note.   It is very important to specify the Service Date field (which will default to the current date) and to correct this if for some reason you are starting a Daily Obs Note for a prior day.   

“Discharge Day Management more than 30 minutes” is a new billing metric with higher RVU’s.  As the name states, it only applies to the Obs note of the physician who dispositioned the patient.   

ED Attestation Note 

This is only visible to Attendings.   Any time a resident or student signs an ED Provider note, it generates a deficiency for an ED Attestation Note.   There are 2 standard templates: 

• Brief – for those attendings who want to write a simple paragraph and defer much of the clinical content to the resident note. 

• Comprehensive – matches the full ED Provider Note template for those who want their attending note to be able to stand alone as a record of the visit.   

Progress Note 

This is a catch all for notes that do not fit into any of the above categories.  This is best used for writing a brief note on a signed out patient.   Note that completing this will NOT satisfy an ED Provider Note or Attending Attestation Note deficiency. 

Inpatient Intervention Note 

This is intended to cover situations where the ED physician provides emergency assistance on an admitted patient.  This can cover scenarios where the ED physician goes to the inpatient unit to deliver emergent care or helps with a boarding patient still in the ED.