Hospital medical notes (rest on paper)

Question 1

The hospital medical notes are split in 2 halves.

What kind of information does both the left and right side of the medical notes contain

Answer 1

Left: past + current admission details

Right: Results, letters, Drug chart

Question 2

In hospital medical notes where will you find the most up-to-date information

Answer 2

the middle/centre of the medical notes

Question 3

The ‘Clerking in’ is the admission details. Who are they usually written by? (2)

Answer 3

House officer or senior house officer

Question 4

What kind of information is covered in the ‘clerking in’ process? (7)

Answer 4

General info
Presenting complaint (PC)
History of presenting complaint (HPC)
Past medical history (PMH)
Drug History (DH/DHx)
Social history (SH)
Family History (FH)

Question 5

Whats JVP

Answer 5

Jugular venous pressure

Question 6

whats SOBOE

Answer 6

shortness of breath on exertion

Question 7

BO and BNO

Answer 7

bowel open and bowel not open

Question 8

The Clerking in can note a number of diagnostic imaging techniques like ECG for example. What do these mean:
CXR
AXR
CT

Answer 8

chest x-ray
abdominal x-ray
computerised tomography