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Let’s go over a simple, reliable structure you can use for documenting on-call problems. This is especially useful when you’re seeing unfamiliar patients at night and need to be concise but clear — for yourself, the morning team, and for legal safety.

📋 ON-CALL DOCUMENTATION TEMPLATE¶

1. IDENTIFICATION¶

Start with the basics:
Date, time, and who you are.
This orients anyone reading your note, even hours later.

Example: “May 28, 2025, 0230H – Resident On-Call Note”

2. REASON FOR CALL¶

Next, document why you were called and by whom.
This shows the trigger for your assessment.

“Called by RN at 0215H – patient found on floor.”

3. DELAY EXPLANATION (if needed)¶

If you couldn’t see the patient right away, say so.
Be brief but honest — it’s better than staying silent.

“Assessment delayed due to emergency in Room 10.”

4. ADMISSION CONTEXT¶

Give a one- to two-line background.
Who is this patient and why are they here?

“82-year-old with CHF and COPD, admitted for worsening dyspnea.”

5. HISTORY OF PRESENT ILLNESS (HPI)¶

This is your short narrative:
What happened tonight? Any symptoms? Was it witnessed?
Pull in anything useful from the chart or staff.

Think of it as:
🗣 What they said
👀 What you saw
📁 What’s on file

6. PHYSICAL EXAMINATION¶

Keep it focused. No need to write a full head-to-toe.
Stick to vitals and the relevant systems only.

Highlight what matters — underline abnormal findings.
That makes it easier for the morning team to pick up.

7. INVESTIGATIONS¶

Include only relevant labs or imaging.
You don’t need to list everything — just what helps the picture.

“Glucose 3.2 mmol/L – likely cause of collapse.”

8. ASSESSMENT¶

Here’s where you put the puzzle together.
What do you think is going on?
Start with your provisional diagnosis, then list a few differentials.

Be specific. Don’t just repeat what’s in the reason for call.

Instead of: “Patient fell out of bed,”
Say: “Likely vasovagal due to nocturia + mild dehydration.”

9. PLAN¶

Say what you did, what you ordered, and what needs follow-up.
Did you call anyone? Did you inform the family? Note it.

“Ordered CBC, informed senior resident. Will reassess in 2 hrs.”

10. SIGNATURE¶

Always finish with your full name and role.
If there’s a serious issue, people need to know who to contact.

🔑 Key Reminders:¶

• Be clear, not fancy.
• Focus on the problem, not everything in the world.
• And underline abnormal findings — it’s a small habit that makes a big difference.