Each resident is responsible for a daily note on his or her patient. This should be a problem-oriented note. This means that the problems are listed in numerical order. Each problem is followed by information documenting and establishing the current state of that problem. This area should also include plans for the treatment of the patient that day.
All invasive procedures require a separate note labeled as the type of procedure performed.
These should include the procedure, indication, findings, medications, complications, and follow-up. All notes should be signed, dated, and the time noted. Notes covering more than one page should be signed on both pages. They should determine the work day for the Senior student. This includes determination of when students may carry out various invasive procedures.