Once a resident signs a note, it cannot be edited any longer (i.e. fields clicked on or text entered into the text of the note). All you can do is modify the note. This allows you to free type an addendum at the end of the note and to strike through parts of the resident note you want deleted.
So this is the way I recommend to deal with residents:
1. After the resident finishes seeing the patient, before he presents, he needs to “save and close” his note.
2. The resident then comes to the attending to present.
3. The resident should log on to PowerChart at the attending’s terminal (as well as the terminal in his exam room). The reason for this is so that the note may be edited if necessary and/or signed by the resident at the time of the presentation. If the note is opened in the attending’s version of PowerChart, the attending will become the author of the note and the resident’s name will be deleted.
4. When the attending agrees that the note is complete the resident can sign the note. Upon signing, the resident in prompted for an “endorser”. He should type in or select the name of the attending to whom he presented. The note is then automatically sent to the attending’s “inbox” in PowerChart.
5. The attending clicks on the inbox icon, double clicks on the note marked “pending”, and opens it.
6. The attending clicks on the “modify” icon, adds the attending note, and then signs the note.
7. The note is still attributed to the resident and contains the attending’s note and electronic signature as an addendum.
If you find a better way let everybody know.
Jay H. Mayefsky, M.D., M.P.H.
Professor of Pediatrics and Preventive and Family Medicine
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