Off Service Note
This note tells the oncoming physicians and residents what is going on with the patient when you leave the service.
It matters most for the patients who have been in a long time: long hospital stays, ICU courses, multiple consultants. Those are exactly the patients whose story is impossible to reconstruct from the chart alone.
The date of admission.
List in order of importance.
Tells the story of the patient from admission until now: changes over time, lab studies, procedures, results.
Brief and targeted.
List in order of importance.
Based on the data above.
Medication changes, lab tests, procedures, consults.
Write down the things the next team cannot look up: which family member makes decisions, which consultant to page rather than message, what has already been tried and failed, and what you are worried about. That paragraph is worth more than the rest of the note.