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May 11, 2016 · You should follow good practice principles when taking notes. The General Medical Council says doctors should record their work “clearly, accurately, and legibly,” and it also stipulates that patient notes should be created contemporaneously and kept securely.2 The notes may be scrutinised in medicolegal cases so remember the adage, “if ...
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What you need to know about good note taking Medical notes...
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What you need to know about good note taking Medical notes...
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Feb 8, 2024 · Abbreviations and acronyms are commonly used in medical notes. If you are unfamiliar with common abbreviations, it can make understanding medical notes challenging. We’ve curated a list of medical abbreviations/acronyms to help you understand entries in the medical notes.
- Documentation Basics
- Beginning Your Entry in The Notes
- Documenting The History
- Documenting The Clinical Examination
- Documenting The Diagnosis/Differential Diagnosis
- Documenting The Management Plan
- Completing The Entry in The Notes
What should I use to write with?
You need to use a pen with black ink, as this is the most legible if notes are photocopied.
Patient details
For every new sheet of paper your first task should be to document at least three key identifiersfor the relevant patient: 1. Full name 2. Date of birth 3. Unique patient identifier 4. Home address If a patient labelcontaining at least three identifiers is available, then this can be used instead of writing out the information manually.
Location details
You should indicate the patient’s current locationon the continuation sheet: 1. Hospital 2. Ward
At this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top. The next documentation stepsinclude: 1. Adding the date and time (in 24-hour format) of your entry. 2.Writing your name and role as an underlined heading. 3.Adding your entry in ...
When documenting a history, it’s important to apply a structured approach. Some people document a patient’s history as they take it, whereas others may summarise after they’ve spoken with a patient. If the sections of your documented history are in a different order to what is advised below, it doesn’t matter too much, just make sure you have clear...
On examination
Start by documenting your general inspection (e.g. “The patient was laid on the bed and appeared to be in significant pain”).
Observations
This is where you document the patient’s current observations/vital signs (e.g. BP/Pulse/Respiratory rate/Oxygen saturation/Temperature).
Fluid balance
If the patient’s fluid balance is being monitored write down the input (drinking/IV/NG) and output (urine/stools/drains) that has been measured.
In this section of the clerking, you need to document a diagnosis or suggest a differential diagnosis. Most of the time when you clerk a patient you won’t have a confirmed diagnosis and therefore you’ll need to document some possible differential diagnoses. The symbol for a diagnosis is a singular triangle. The symbol for differential diagnosis is ...
In this section, you need to document your plan in the form of a list. This makes it clear to others reading the notes which investigations are underway and what interventions are planned.
At the end of your entry to need to include the following: 1. Your full name 2. Your grade/role (e.g. Medical student/F2/Respiratory Registrar) 3. Your signature 4. Your professional registration number (e.g. GMC number) 5. Your contact number (e.g. phone/bleep)
- Charlotte Sandberg
> Medical notes should be available at all times to those giving input to the patient and should be stored appropriately. > The current admission should be filed chronologically in the correct section of the notes.
In meeting the standards of Good Medical Practice you should: Be fully versed in the use of the electronic health record system used in your organisation and record clinical information in a way that can be shared with colleagues and patients and reused safely in an electronic environment.
Jan 9, 2014 · Notes are often poorly maintained and sometimes patient notes are not readily available. 1 It is common to find illegible entries, offensive comments, and missing information, and there is often inconsistency between entries by doctors, nurses, and midwives.
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Feb 17, 2017 · The ability to write in a patient’s notes effectively is an essential skill all medical students need to learn. Accurate documentation is also incredibly important from a medicolegal perspective.
