Interpretation of medical notes Flashcards

1
Q

why keep medical notes?

A

1) Reminder – diagnosis, what needs to be done etc
2) Communication - between healthcare professionals
3) Medicolegal document – in case of civil/criminal action by a patient or their representative

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2
Q

list the people that make medical notes

A

doctors, nurses, pharmacists, specialist nurse, SALT, OT

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3
Q

what do the nursing notes contain?

A

1) Admission details: next of kin, social situation
2) Care plans (usually standardised): e.g. pressure sores, nutrition, etc.
3) Observations charts: TPR, SaO2, stools, fluid balance, food, etc.
4) Daily progress: care given, meds, eating
5) Discharge information

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4
Q

what other information do the notes contain?

A

1) Medical notes – past & current
- Admission form
- Ambulance form / GP referral
- Clerking in & progress
- Investigations, diagnosis, treatment, monitoring
- Discharge prescription
2) Other stuff – charts, results, letters

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5
Q

how are medical notes laid out?

A

1) Split into 2 halves
- Left = past & current admission details
- Right = results, letters, charts etc.
2) Generally most current information is in the centre

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6
Q

what is clerking in?

A

comprehensive history and full examination of a patient taken when the patient is going to be admitted to hospital. This includes initial investigation results, the team’s differential diagnoses and a management plan.

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7
Q

what are the 7 things the clerk consists off?

A

1) Take a FULL History
2) Perform a THOROUGH Examination of all systems
3) Document your findings
4) Perform relevant Investigations
5) Formulate a list of Differential Diagnoses
6) Create a Problem List
7) Decide on a Management Plan

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8
Q

what is ROS?

A

1) ROS – review of systems: Dr’s examination, concentrating on most relevant areas and recording both positive and negative findings

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9
Q

what is O/E ?

A

1) O/E – on examination: General info on pt appearance

- E.g. pale, sweaty

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10
Q

what is JACCOL?

A

jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy

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11
Q

describe how cardiovascular information is documented.

A

1) Jugular venous pressure (JVP): can be normal → or raised ↑
2) Pulse (P or HR):
- beats per minute (bpm)
- regularity
3) Blood pressure (BP)
4) Heart sounds (HS)
- I — II — O

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12
Q

describe how respiratory system information is documented.

A

1) Respiration rate (RR): breaths per minute
2) Shortness of breath: (SOB/SOBOE)
3) Air entry (AE)
4) Chest clear: may see an arrow drawn through indicating the chest is clear
5) Crepitations (creps): lungs with stars in the bottom corner

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13
Q

describe how Gastrointestinal system information is documented.

A

1) Gastrointestinal system (GI / GIT / abdo)
2) Bowel sounds (BS)
3) Bowel movements: (BO / BNO)
4) hexagon with a circular area near the bottom indicating : Tenderness, Pain, Swelling

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14
Q

what 7 things do you examine during the thorough examinations part of clerking in ?

A

1) General appearance
2) Cardiovascular
3) Respiratory
4) Abdominal
5) Locomotor: CNS – central nervous system
- Alertness, Glasgow coma scale (GCS)
- Test nerve function (e.g. stroke)
6) Neurological: PNS – peripheral nervous system
- numbness in hands/feet
7) Ortho – orthopaedics (bones /joints)

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15
Q

what occurs after the whole clerking in process?

A

1) Post-take ward round (PTWR)
- Patient reviewed by senior doctor (usually consultant)
- Further treatment plan made
2) Follow up
- Patient visited as needed and progress noted

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16
Q

The first stage of clerking in is to take a full history. outline what this contains

A

1) Presenting Complaint- PC or C/O: ( SOB, unwell, “off legs”, collapse, confusion, fall)
2) History of Presenting Complaint- HPC ( when started? reliving factors, action taken)
3) Past medical history- PMH (previous admissions)
4) Drug History (including allergies)
- stopped meds,dose, allergies. often inaccurate
5) Family History- FH ( risk factors, cancer, heart disease)
6) Social History- SH (occupation, smoking, alcohol)
7) Systems Review
8) Ideas, Concerns and Expectations
9) Admission details: History, examinations, investigations, management