Quincy Family Practice Program
Residents Manual
Documentation
Documentation of clinical activities is of utmost importance. This information will be needed in obtaining hospital privileges in the future. It is most important to document every procedure that is done. All hospital-based procedures must be recorded in procedure logger and uploaded to New Innovations. Procedures logs will be reviewed at semi-annual Director-Resident reviews. Also of some importance is documenting the type of patients cared for.
The residents will dictate each procedure, hospital H&P, and discharge summary that is performed. Each resident will receive a copy of each of these dictations. It is suggested that the resident file these dictations in a very safe place. They will be the basis for your documentation recorded in New Innovations.
Also, all clinical activities performed at the Quincy Family Practice Center are recorded in the computer system at the SIU School of Medicine in Springfield. A printout of number of patients, type of diagnosis and procedure, etc will be provided to each resident.
Please be cognizant of dictation contents. Ensure that the necessary information in provided without being excessively wordy.
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