Medical Record Documentation for House Officers
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Histories & Physicals
- Must have been done no more than 7 days prior to admission
- Completed within 8 hours of admission
- Must have been done no more than 7 days prior to admission
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Progress Notes
- Completed daily
- Completed daily
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Surgical/Procedure notes
- Done immediately upon completion of the procedure or operation
- Verbal Orders
- Signed within 24 hours
- Signed within 24 hours
- Telephone Orders
- Signed within 14 days
- Signed within 14 days
- Discharge Summaries
- Completed within 48 hours