Focusing on template development to standardize the structure of electronic notes to improve handovers in the hospitalist setting, the project was initiated through PQI in 2020. At completion, the VJH Hospitalist group had a 65% (from 10%) adoption rate of electronic record keeping when providing in-patient care. The project did not focus on the content of the notes generated, but did strive to develop templates through multidisciplinary stakeholder engagement. The majority of hospitalists in the program felt that electronic notes improved care and handover, especially when a single physician are required to field calls for 130 – 180 patients at night.
1 year after the project was completed, the adoption rate for electronic documentation in the hospitalist service at VJH was 100%. Since then, it is considered the standard of care at VJH and all locums, new contractees, NP’s and AP’s working in the program are expected to document electronically from day 1. In partnership with Digital Health, new providers can request an onboarding session to ensure that they are comfortable using the software to generate their notes.
HOSPITALIST ADMISSION NOTE
[Insert Hospital]
ID: []
Referred by: []
REASON FOR ADMISSION:
[]
HISTORY OF PRESENTING ILLNESS:
[]
GOALS OF CARE:
[]
PAST MEDICAL HISTORY:
[]
PAST SURGICAL HISTORY:
[]
ALLERGIES:
[]
HOME MEDICATIONS:
[]
SOCIAL HISTORY:
[]
IMMUNIZATIONS:
[Up to date]
FAMILY HISTORY:
[None relevant]
EXAMINATION:
Vitals: []
General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I – XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]
SPECIAL INVESTIGATIONS:
[]
ASSESSMENT & PLAN:
[]
DISPOSITION:
Admit to VJH Hospitalist
VTE: []
Diet: []
MOST: [If you made any changes or had discussions, leave out if captured in above section]
Consults: [PT, OT, TL, SW etc]
EDD: []
Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
HOSPITALIST PROGRESS NOTE
[Insert Hospital]
MOST []
SUMMARY:
[80-year-old female admitted with CHF.]
TODAY:
[Capture SOAP elements reflecting changes in patient’s condition, reasons for change of treatment and outcome of treatment]
Plan:
[List today’s plan]
ACTIVE ISSUES:
[Problem list]
BARRIERS:
[]
PMH:
[]
This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
HOSPITALIST DISCHARGE SUMMARY
[Insert Hospital]
MOST []
DATE OF ADMISSION: []
DATE OF DISCHARGE: []
DESTINATION: []
PRIMARY DIAGNOSIS:
[]
SECONDARY DIAGNOSIS:
[]
CONSULTATIONS:
[]
PROCEDURES:
[None]
PAST MEDICAL HISTORY:
[Import from progress note and ensure updated with new findings]
DISCHARGE MEDICATIONS:
[]
SUMMARY OF ADMISSION:
[Provide a one paragraph summary, can import summary and just add information]
FOLLOW UP AND RECOMMENDATIONS:
1. [Recommended follow up labs, imaging etc ]
2. [Results pending at time of discharge]
3. [Referrals submitted while in hospital ]
Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.
To access and copy and paste the template into MModal or directly into Meditech, click on the Clinical Menu item in the header.
As this project was started prior to the AI era, we invested in a website to make retrieving templates easier. The website is still being used today and the templates can easily be retrieved by clicking on the Clinical menu item in this website. All templates were programmed to be dictation ready and allows providers to complete the sections as they see fit. Templates can be pasted directly in Meditech or in the MModal software for personalization.
We will be working on developing prompts that can be used with AI providers to the note structure remains unaltered. Stay tuned.
Learn more about our templates here.