VER EMR documentation/Handover

VER - AI software utilized for scribe purposes. Pt/representative aware and agreeable. Nursing documentation has been reviewed in EMR. (This is a conversation between nursing, who is at a nursing station, and the physician on the phone, but you do not need to put that in the note.) History: (If there are completely unrelated problems, for example, an ingrown toenail and also a cold, separate them under headings labelled Issue #1: Cold, Issue #2: Ingrown Toenail, Issue #3: Diabetes, etc. Only do this if I clearly state they are separate issues. Issue #1 will always be the primary issue and should follow the full structure below. Issue #2 and onward must be more brief, focusing only on key details I mention.) (The information under this heading can be brief and only highlighting key components, as most will already be in the nurses note. It can almost be treated as a summary.) -[recent visits to the nursing station, timeline of events, and specific diagnoses or outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[for pediatric patients include hydration status: wet diapers, urinary output, bottles/fluid intake, etc.] (Can omit if obviously not contributory to the story such as an older pediatric patient with psychiatric issues or a musculoskeletal issue. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[pertinent negatives from a review of systems if not mentioned above or not better put in the exam section] (For example no headache, no chest pain, no shortness of breath, no hematemesis, etc. Do not include physical examination findings here, but rather in the physical exam section. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) Past Medical History: -CPP reviewed -[relevant past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[home medications, OTC medications, supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[immunization history and status] (Include for pediatric patients; otherwise only if explicitly mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[birth history for pediatric patients] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[social history such as smoking, alcohol, drugs, occupational exposures] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[other relevant history or contributing factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[allergies including reaction details] (If allergies present, write in ALL CAPS. If no known drug allergies, write normally "Allergies: NKDA". Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) RN's Physical Examination: (This can also be a summary, with key points listed.) [vital signs and key physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[for pediatric patients include cap refill, hydration status, mentation, and general appearance] (For pediatric patients, include immediately after vitals. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (For additional issues such as Issue #2: Ingrown Toenail, Issue #3: Diabetes, etc., include only brief and relevant exam findings in point form under the corresponding issue heading.) (Do not include history findings here, include that in the history section.) Investigations: (This can also be a summary, with key points listed.) -[completed investigations with results only] (Group related labs on one line: Chem 8 on one line; VBG pH/pCO2/lactate on one line; troponin on one line; urinalysis on one line. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (For additional issues such as Issue #2: Ingrown Toenail, Issue #3: Diabetes, etc., include only the brief relevant investigations and results under that issue heading in point form.) (Do not list planned or ordered investigations here; document those under Management Plan.) Impression: -[likely diagnosis and differential diagnoses with detailed reasoning and comments discussed] (Include on every visit. Include as much detail as discussed. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Never infer or assume diagnosis or differentials.) (For additional issues such as Issue #2: Ingrown Toenail, Issue #3: Diabetes, etc., provide only a brief, focused impression for each, under the corresponding issue heading in point form.) Management Plan: (This is to be a bit more detailed and will be used to give orders to nurses.) -[investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[treatments planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) -[counselling, referrals, lifestyle advice, or other actions taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (For additional issues such as Issue #2: Ingrown Toenail, Issue #3: Diabetes, etc., provide a short management plan under each corresponding heading in point form.) -[return to care instructions] (Write all on one line. Only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, or continuing care. Use only what is explicitly stated in the transcript, contextual notes or clinical note. If information for a placeholder is not mentioned, leave the section blank without stating it was omitted. Use SI/Canadian units.)