Twelve note phrases
Twelve of the sixty eight. Plain text. Tap any phrase to copy it straight into your phrase library. No signup, no email.
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.capacity Decision making capacity assessed for the specific decision of ***. The patient [was/was not] able to communicate a choice, [was/was not] able to understand the relevant information, [was/was not] able to appreciate the situation and its consequences, and [was/was not] able to reason about the options. Conclusion: capacity [present/absent] for this decision on @DATE@. Basis: ***.
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*** marks a blank you fill. [brackets with slashes] mark a choice. Every one is written so that pasting it without edits is still true. None of them claims a thing was done for you. Documentation language only, with no drug or diagnosis. Adapt every phrase to the patient and to your institution's policy. Not legal, billing or clinical advice.
.rosneg
Review of systems: limited to the systems documented above, which are negative except as noted in the history of present illness. No system other than those was reviewed. Systems listed above that were not asked about directly, or were answered by a source other than the patient: ***.
.codestatus
Code status discussed with the [patient/health care proxy ***] on @DATE@. Decision: [full code/do not resuscitate and do not intubate/do not resuscitate, intubation acceptable/do not intubate, chest compressions and defibrillation acceptable/***]. The [patient/proxy] [demonstrated understanding/had questions answered/***]. Order in the chart: [entered/to be entered by ***].
.overnight
Overnight events: [no acute events/***]. Reviewed for this note: [nursing notes/vital sign trends/intake and output/overnight results/***]. Ordered overnight and still not back: [nothing/***].
.awaiting
Awaiting: *** (ordered ***, expected ***). Responsible for reviewing the result: ***. If it is abnormal the plan is ***.
.dcfollowup
Follow up: *** with *** on *** (appointment [made/to be scheduled by the patient/to be scheduled by the clinic]). Additional follow up: ***.
.dcinstruct
Discharge instructions given [verbally and in writing/verbally only]. Language: [the patient's stated preferred language, ***/spoken through interpreter *** in ***, with the written copy in ***/***]. Teach back: [the patient or caregiver restated ***/not completed because ***].
.consultrec
Recommendations: 1. *** 2. *** 3. *** Communicated to the primary team: [discussed with *** in person on @DATE@/discussed with *** by phone on @DATE@/by this note only, and *** will contact *** by ***].
.proctimeout
Time out completed at *** immediately before the procedure: identity confirmed by [two identifiers/***], procedure and site confirmed [with the patient/against the consent form/against the consent form and the imaging/***], site [marked/marking not applicable], allergies [reviewed/***], team introductions [done/***], and all team members [in agreement/***].
.critical
Critical result: *** reported by *** at *** on @DATE@. Received by me at ***. Action: ***. Informed: [the patient at ***/the family at ***/the patient and family at ***/not yet, and *** will inform them].
.capacity
Decision making capacity assessed for the specific decision of ***. The patient [was/was not] able to communicate a choice, [was/was not] able to understand the relevant information, [was/was not] able to appreciate the situation and its consequences, and [was/was not] able to reason about the options. Conclusion: capacity [present/absent] for this decision on @DATE@. Basis: ***.
.signout
Signed out to *** at ***. Anticipated issues overnight: [none/***]. If ***, then ***. Contact for escalation: ***.
.teleopen
Telehealth visit conducted by [video/telephone] on @DATE@. Patient location: ***. Clinician location: ***. Limitations of a telehealth visit for this problem: [explained to the patient/***]. An in person visit: [offered/offered and declined by the patient/not available because ***]. Consent to proceed by telehealth: [given by the patient/given by ***/***].
The other fifty six
Admission, progress, discharge, consults, procedures, safety and telehealth. Plain text, two PDFs and an import bundle, every later edition free. Thirty day refund, keep the files.
Three of the fifty six, in full
.refusal The patient declined *** after discussion of the reasons for the recommendation, the risks of declining including ***, and the alternatives. Capacity for this specific decision was [assessed as present and documented above/assessed as present and documented in a separate note on ***/not formally assessed, and the basis for proceeding was ***]. The decision was respected and the plan adjusted to ***. Offer remains open.
.disclosure Event disclosed to the [patient/family] on @DATE@ at ***: ***. Present: ***. Covered: [the facts as known/the facts as known and the questions asked/the facts as known, the questions asked and the next steps/***]. Follow up meeting: ***. Risk management [notified at ***/to be notified by ***].
.interpreter Interpreter used: *** language, [in person/video/telephone], interpreter ID or name ***. Conducted through the interpreter: [every discussion recorded in this note/***].
Get all 68 for $10 →The names of all fifty six
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