- Chart review
- Records outside the hospital
- Records inside the hospital
- Interview and examine the patient
- History
- Chief complaint and past medical history
- Review of systems, family history, social history
- Verify medication list and allergies
- Identify single family member for communication
- Identify patient’s advance care wishes
- Physical
- Notify the primary team
- Enter orders, if applicable
- Complete documentation
- Update sign-out
- Complete billing