The "Hospital Course" is a problem oriented charting (POC) building block available to inpatient encounters. It allows clinical teams to collaboratively update a running summary of the patient's hospital experience. The text block can then be pulled into progress notes (e.g., weekly handover notes), transfer notes and discharge summaries. There is but one note per inpatient encounter, and all clinicians can share in its Wiki-like maintenance.
Hospital Course editing can be accessed by:
- Using the hospital course section in problem list and POC navigators.
- Selecting the "hospital course" title from the POC sidebar (opens pop-up editor)
- Selecting any related document section title (e.g., "Inpatient Course" in discharge summaries; opens pop-up editor).
- Selecting the right-pointing arrow in the inpatient sidebar index next the "Problem Charting" item (opens editor in sidebar).
A standardized Hospital Course format and style can maximize impact:
- Brevity - Intended as a high-level overview of what happened during an encounter, keep to a maximum of a paragraph or two. This is not a detailed diary, but rather a tally of key milestones. For example, rather than listing all antibiotic agent details, indicate things like when step-down from parenteral to oral antibiotics occurred. Do not repeat information that will appear elsewhere in final documentation (e.g., discharge summary).
- Format - A succinct prose comment on the overall hospital experience, followed by a bulleted list of key milestones, is preferred by the intended audience (e.g., community providers post-discharge).
- Time indicator - It is better to indicate time intervals by the hospital day rather than by actual dates (which force the reader to calculate the relative timing of events).
