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General Guidelines for Documentation
General Guidelines for Documentation
Locking encounters All visits must be locked by the end of the date of service but no later than 48 hours, for legal reasons. Once a chart is locked, no edits to the progress note can be made.
The eCW progress note is divided into SOAP:
Subjective
History of Present Illness (HPI) HPI Documentation What is an HPI? A brief account of a patient's medical issue.
Nurse visit types For any nursing care that is provided, a nurse visit type (triage, RN visit, Procedure assistance, etc) must be selected.
When a visit type is not selected, then the work nursing does is not captured.
Templates Always use applicable template, when available.
Always use the interpreter template when communicating with patients in a language other than English (even if you are the "interpreter")
Objective
Vital Signs Vital signs should be documented at all EMV's, triage/walk-in visits, and other visits as appropriate.
VS do not need to be documented for vaccines, injections, ear lavages & education visits - unless the nurse has noted a concern with the patient condition.
Assessment (ICD10 codes)
Plan
Treatment Vaccines, injections, labs, etc are ordered and documented in this section.
Procedures Use the procedures link to document PO medication administration, wound care, and other in-clinic procedures.
Documenting labs, medications, and vaccines
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