Trainee Reconciliation

The following Powerscribe templates exist for the purposes of documenting agreement or disagreement with the resident or fellow overnight report. These templates are the recommended methods for including this in the final report:

• overnight agree – recommended for inclusion when the final report agrees with the preliminary report
• overnight disagree – recommended for inclusion when the final report disagrees with the preliminary report. Details about changes should be included

Communication documentation

The following Powerscribe templates exist for documenting findings which need to be communicated with ordering providers:

• critical find – mandatory for the the specific findings in the Emory policy. This includes only NEWLY IDENTIFIED:

Acute Hemorrhage • Acute Arterial Dissection or Occlusion • Acute Large Vessel Infarction • Brain Herniation • Hydrocephalus • Depressed or Open Skull Fracture • Airway Compromise • Epiglottitis • Malpositioned Support Device

And

Unstable Fracture • Spinal Cord Compression

• important find and additional find are recommended methods for documenting communication with ordering physicians for other findings.