Typhon Documentation

Documentation

Students should document in Typhon for every patient that they see. The following information is required:

1. Student information (semester, course, preceptor and clinical site)
2. Patient demographic (age, race, gender)
3. Clinical site information (time with patient, type of decision-making, student participation, reason for visit, chief complaint, type of HP)
4. ICD 10 and CPT billing codes
5. Medications (name, dose, frequency and duration)
6. A brief SOAP note in the clinical notes

Example given of a brief SOAP note

S: Subjective—A statement in the patient’s own words regarding the chief complaint (CC), which explains why the patient has presented to the facility (this is usually in quotes). Follow this with a HPI that follows OLDCART.

O: Objective—This should include vitals and an assessment of “at least” the chief complaint. If the patient presents with a sore throat you would include ears, nose, and throat. Pay attention to your codes. If you code three body systems then you need to assess three body systems.

A: Assessment—medical diagnosis.

P: Plan—This is your treatment and brief education. All medications need to include name, dose, frequency and duration. This would also include result of any tests or labs.

Note: Each practicum course professor may request additional information/documentation, however, try to minimize documentation time in Typhon as you will also need to document in the EMR at the clinical site.