Quick reference

Checklists and lists to use at the point of care. Checkboxes are for your own use and are not saved.

Before you sign a note

Patient identifiers and encounter date are correct
Chief complaint and history reflect this encounter
Copied-forward text has been reviewed and updated
Assessment states clinical reasoning and supports each diagnosis
Plan addresses each active problem with next steps
Medications and allergies are reconciled
Orders, referrals, and follow-up are documented

Discharge handoff

Principal and secondary diagnoses are documented
Pending results and responsible clinician are listed
Medication changes are explained
Follow-up appointments are scheduled and recorded
Patient education and return precautions are documented

Telehealth visit documentation

Visit modality (video or audio-only) is recorded
Patient and provider locations are recorded
Consent for telehealth is documented
Limits of the remote exam are noted
Technical issues and contingency plan are documented

Do-not-use abbreviations

Item	Use instead
Do not use: U	Write "unit" in full
Do not use: QD / QOD	Write "daily" or "every other day"
Do not use: trailing zero (5.0 mg)	Write 5 mg
Do not use: lack of leading zero (.5 mg)	Write 0.5 mg
Do not use: MS, MSO4, MgSO4	Write "morphine sulfate" or "magnesium sulfate"