Physician Name: Date of Shift: Cts Name

PHYSICIAN NAME: DATE OF SHIFT: CTS NAME:

PHYSICIAN PREFERENCES TEMPLATE

Fill out the below components based upon your shift experience with the physician and what they have specified or you have observed regarding their particular style of documentation. Do not include details associated with department workflows; those belong with your Shift Objectives form. Keep this relevant to an individual level.

HPI

Ex: Do they want all pertinent pos/neg reiterated in HPI? Are there components they always want included (pain scale, severity, etc.)?

ROS

Ex: Do they want a complete ROS filled out i.e., all systems assumed negative if not directly asked? Do they have certain components that they will always ask? What are those?

PMHx

Ex: Are there certain diseases they will always ask about? Do they want certain things marked negative if they are absent in the history?

Social Hx

Ex: Do they prefer you cc over from nurses notes? Do they always ask about certain things?

Family Hx

Ex: Do they prefer you cc over from nurses notes? Do they always ask about certain things?

PEx

Ex: What are the PEx components that they will always ask and always want documented? Do they call out abnls in room? Do they do a head to toe on ALL patients?

Course (MDM, Procedures, Progress)

Ex: What are some key phrases they always want included in their MDM? Are they brief or lengthy? Do they have a certain way to document rechecks/family discussions/pt updates?

Vitals

Ex: Do they want updated vitals documented? Do they interpret anything outside of O2?

Ex: Do they want to include all complaints and PEx findings as dx? Do they prefer that every diagnosis be “acute”?

D/C instructions

Ex: What are some key phrases they want written in d/c instructions? How do they prefer their exit interview be documented (d/w pt and family risks of….)

Other Notes/Concerns

Ex: NEVER do (fill in blank)! Or ALWAYS mark (fill in the blank). Are they particular about anything, such as following up on XR/lab/consult calls, new pts, re-evals, critical care, etc.?

Radiology:

Ex: Any specific way they want CTs documented? Radiologist interp only? Contemporaneously? (this may be a departmental thing but specify any physician prefs here regardless)

See examples above

Miscellaneous:

ANY other particularities that the physician wants done/written/acted on during the shift that makes their scribe experience particularly satisfying or dissatisfying, if not done?