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Connect Care Basics
Connect Care Basics
If you need any help - the Official Physician's Connect Care Manual has many useful tip sheets to use
If you have immediate issues - please call the Help Desk (1-877-311-4300) - Press 1 + 1 + 2
For any issue or if you have great ideas - please contact Dr. Tim Chan (twchan@ualberta.ca)
Documentation
Documentation
- CONSULT Notes
For any "new" consultation from the ED during the day - medical students / junior or senior residents / fellows / staff should create a CONSULT note as their initial documentation
The consult note can be linked to the pending order
If there is no need (straightforward case) or no time (on call) - the ED team is not expected to complete an H&P note
- H&P Notes
If there are learners - medical students / junior residents - they can use an H&P note to do their documentation ( DURING THE EVENING/NIGHT)
The senior resident in the evening/night should complete a Consult note
If patients are moved up to the wards and no H&P note has been done - the receiving team should use an H&P note to do their first documentation
this could be the resident on call, documenting the facts of the case
this could also be the attending physician the morning after the patient is admitted
- Things to Avoid for Notes
Do not just copy the Consult Note to the H&P note - avoid duplication
Ideally the notes should reflect your own thoughts
Try not to write notes for the sake of documentation completion. If you have nothing to add, don't write anything.
If you feel compelled to - you could enter "see consult note dated MON/DD for full consultation"
- Edits / Attest / Co-sign
Co-sign and Attesting notes should be reserved for Fellows and Attendings
If you are the senior resident and you want to add on to a trainees notes - use the "Edit Button" and remember to attribute which sections were written by each person
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