Dictation+policy

=Dictation Policy= (Per a decision of the Ambulatory Policy Committee, effective July 1, 2008)


 * What must be dictated:**

1. **Pre-op H&Ps**: if the patient is being admitted post-op or if the patient is medically or psychosocially complex.

2. **Consults**:  3. **Transfers:**  4. **Surgical pre-op note** by the surgeon including the indications, type of surgery and anesthesia
 * A) Assessment and plan for all initial consults
 * B) Consult notes when there is a significant change in diagnosis, patient status or plan
 * C) All consults done on referrals from CPN providers
 * A) All transfers to another site or institution (i.e. hospital, ED, L&D for eval)
 * B) Planned transfers of care from one clinician to another


 * What is highly recommended to dictate:**
 * 1) All consults
 * 2) All consult requests except very routine ones (i.e. for eyeglasses, screening flex sig, optho for diabetes screening)
 * 3) Behavioral and medication contracts
 * 4) Progress notes for medically or psychosocially high risk or complex patients on presentation and at each significant change in status
 * 5) Progress notes for patients who are routinely followed at more than one site
 * 6) Clinical notes for Anticoag clinic patients if they are seen at another site and have new illnesses/medications that could affect their coagulation studies
 * 7) Management of critical abnormal test results called to a provider outside of the hospital

(last updated by Tai, May 2008, per an email from Chris Farnitano, May 29, 2008)