Summarize this chapter into important points

Accurate, concise documentation of on-call problems is essential for the continued efficient care of hospitalized patients. In many

instances, you will not know the patient you are asked to see, and you may not be involved in his or her continuing care after your night on call. Some problems can be handled safely over the telephone, but in the majority of situations, a selective history and

physical examination are necessary to diagnose and treat the problem correctly. Documentation is recommended for every patient

you examine. If the problem is straightforward, a

brief note is sufficient; if the problem is complicated, however, your note should be concise but complete.

Begin

by recording the date,

time, and who you

are. For example:

Aug. 10, 2016, 0200. "Medical student on-ca11 noW' or "Resident

on-ca11 note."

State who called you and at what time you were called. For

example:

Called to see patient by registered nurse (RN) at 0130 because the patient "fell out of bed."

If your assessment was delayed by more urgent problems, say so. A brief one- or two-sentence summary of the patient's admission

diagnosis and

major medical problems should follow. For example:

This 74-year-old woman with a history of chronic renal failure, type 2 diabetes mellitus, and rheumatoid arthritis was admitted 10 days ago with increasing joint pain.

Next, describe the history of present illness (HPI)-the "

fall out

of bed"-from the viewpoint of both the patient and any wi