Comment on Progress Notes

Learn to use available tools in EPIC

In your assessment, remember diagnoses are nouns

E/F, R/O ie evaluate for, or rule outs are verbs and thus go into the plans

In your plans

Data that is important but missing, eg structured cognitive assessments, should be included in the plan as a missing element to be collected

While writing orders for medications help the reader by using clear consistent language

Medications are any ONE of the following:

Continued – ie at same dose and schedule

Increased or tapered up

Decreased or tapered down

Stopped, discontinued or terminated (helpful to add a few words on reason)

Start, initiated, (helpful to add a few words on target sx)

Crossover ( followed by taper up “x” and taper down “y” comments)