Table 2.
Data field | Method of inclusion | Specialty |
---|---|---|
SIGNOUT mnemonic | Text at top of note template; not in printed report |
All |
Location | Automatic feed from EMR | All |
Name | Automatic feed from EMR | All |
Medical record number | Automatic feed from EMR | All |
Admission date | Automatic feed from EMR | All |
Gender | Automatic feed from EMR | All |
Age | Automatic feed from EMR | All |
Weight | Automatic feed from EMR | All |
Diet | Automatic feed from EMR | Pediatrics |
Visit reason (as input by ED or registration) |
Automatic feed from EMR | All |
Care providers | Manually select from list of providers assigned to patient including service, primary team, consulting team, attending, resident, intern, PA, care coordinator | All |
Resident pager # | Manual entry | Neurology |
Allergies | Automatic feed from EMR | All |
Code status | Manual entry | All |
Family contact info | Manual entry | All |
Conservator status | Automatic feed from EMR | All |
PMD/Consultants | Manual entry | All |
History or Hospital course | Manual entry; option to insert text from progress note | All |
Operations | Manual entry; option to insert text from progress note | Surgery |
Procedure | Manual entry; option to insert text from progress note | Gynecology, obstetrics |
Prenatal labs | Manual entry; option to insert text from progress note | Obstetrics |
Oncology history | Manual entry; option to insert text from progress note | Gynecology |
Medications | Automatic feed from EMR [optional] | All |
Anticipated discharge date | Manual entry | All |
Anticipated discharge tomorrow | Manual entry | All but obstetrics and gynecology |
Discharge parameters | Manual entry | All but obstetrics and gynecology |
Care coordination needs | Manual entry | All but obstetrics, gynecology and psychiatry |
W10 [skilled nursing facility paperwork] |
Automatic feed from care coordinator note | All |
To do list | Manual entry | All |
Other notes | Manual entry; option to insert text from progress note | All but gynecology |
Hgb, Hct, PT, PTT, Ca, ionized Ca, WBC, bilirubin, cyclosporin level, tacrolimus level |
Automatic feed from EMR | Surgery |