• Instead of the admitting resident/intern being responsible for all dictations,
  it will now be the *discharging* resident/intern who is responsible.
  
• No change for long stays (more than 3 days)
  -Discharge dictations for >72h stays by admitting/primary intern
  
• No change for interim dictations
  -Interim dictations for >30days by admitting intern/primary intern
  
• Document first and last name of resident and attending on last page of chart

Important Points to Remember

1. On the day of discharge, the last page in the chart should clearly state the
FIRST AND LAST NAMES of the dictating resident and attending. Medical records uses the last page of the record to determine who is responsible for the dictation. They do not access SCM for this information. As an example, please document the dictating attending and resident names on the last page of the chart as follows:

Dictating Resident: Rob Finkelstein
Dictating Attending: Jeff Kahn

2. Interim summaries are only for patients who have admissions for >30 days.
Some of you have been dictating for less than 30 days because you are going
off-service. We realize that you are well intended and trying to save work for
the person following you, but this approach leads to excessive paperwork and
transcribing that is unnecessary.

3. When dictating, you need to mention who the responsible attending is for that
patient. If you are dictating an interim summary, the attending identified
needs to be an attending who wrote in the chart during the dates for which you
are dictating. For example, if Jeff Kahn and Ali Vaezy were attending
during the period for which you are dictating, identify either ONE of them as
the attending.

If you are dictating a final discharge summary, the attending identified should
be the discharging attending. If Al Friedman was the attending for the
majority of the hospital course, but Pete Bowers wrote the discharge note, Pete
Bowers is the dictating attending.

4. Identify the dates for which you are dictating. This is especially important
for interim dictations.

5. Documentation on day of discharge. Please write a brief statement:
"Patient has remained on room air overnight, has no increased work of
breathing, and is taking good po. Will be discharged today. Please see
discharge summary for details.”

This is where you should also list the dictating attending and resident by first
and last name.

Please let us know if you have any questions.