We have a program that was created in-house that links to the EMR (developed/designed several years ago by the IM residents in conjunction with the IT dept...out of frustration with the word doc system, I think). It has fields to fill in CC, HPI, hospital course, ongoing problems, relevant studies, things to do, notes for night float etc. Since it can access the EMR it auto-populates the current med list (as well as recently d/c'd meds), the most recent labs and patient info (contact name/number, PCP, etc). It also has functions where each team member can generate their own list of patients, but whatever has been manually entered for that patient (HPI, hospital course etc) gets carried over to anyone else's list that patient appears on (e.g. the senior resident, or when a patient transfers services or in/out of the unit). It's accessible from any computer in the hospital.
It's a pretty good system...and something I definitely took for granted until discovering on the residency interview trail that other places use word docs, etc.
