Admissions

• Call bed booking (ext. 75106) and give patient name, unit #, MRP, admitting diagnosis, disposition, and isolation status
• Write full admission orders (include MRP on-call, transfer care to ‘Team 1/Team 2’ in a.m.)
• Ensure history & physical is documented on chart

Charting

• Admission note should include complete history & physical, assessment & plan
• Progress notes should be written daily on every patient
• Summary notes are very helpful on a weekly basis, of all major issues, investigations, etc. These should be written by residents on Fridays and clerks on Thursdays.
• Off-service notes (at the end of a month/rotation) are also helpful and expected.
• Please refer to Dr. Roy’s guidelines for chart-keeping expectations (attached).

Transferring patients

• When transferring patients, please verbally notify the resident on the new service (staff to staff handover should also take place independently).
• Transfer orders to general pediatrics, Level 2 Nursery are expected.
• Dictate transfer summary and write brief transfer summary in chart.

Discharging patients

• Dictate a discharge summary for every pediatric patient. This should include dates of admission/discharge, admission/discharge diagnosis, discharge medications, follow-up plans, brief history & physical, pertinent investigation results and summary of course in hospital. See templates for general peds, Level II nursery, NICU, etc.
• Complete facesheet prior to patient leaving hospital – this will be faxed to family physician’s office at the time of discharge.
• Complete any prescriptions, CCAC requests, other forms prior to discharge.