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  • CPRS - Writing Notes at the VA
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Notes at the VA

Writing notes at the VA is the same as writing notes in any medical chart, though there are a few specific VA policies that need to be followed.


Abbreviations

The VA is now prohibiting the use of specific abbreviations in notes. QD and QOD should be written as "daily" and "every other day." U or IU must be spelled out as "units" or "international units."


Attestations
  • Residents should document attending physician presence (e.g. "This patient was seen by and staffed with Dr. X").
  • Students should document their role (e.g. "John Doe, MS3, evaluated this patient under the supervision of Dr. X who interviewed and examinded the patient and directed the medical decision making".)
Signing Notes
  • Residents DO sign their notes, but must complete the encounter form first.
  • Students DO NOT sign their notes. Students should do this instead:
    1. Click on the "Change" box in the upper right hand corner of the screen.
    2. Change the author to the attending who supervised the care of that patient.
    3. Click "OK".
    4. Right click on the note.
    5. Select "Save without signature". The note will then be sent to the attending for editing and signing. The student will no longer be able to edit the note.
  • The attending will complete the encounter form if the student has not already done so.




Done with the note?



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