Interpretation of medical notes Flashcards
why keep medical notes?
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
list the people that make medical notes
doctors, nurses, pharmacists, specialist nurse, SALT, OT
what do the nursing notes contain?
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
what other information do the notes contain?
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
how are medical notes laid out?
1) Split into 2 halves
- Left = past & current admission details
- Right = results, letters, charts etc.
2) Generally most current information is in the centre
what is clerking in?
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.
what are the 7 things the clerk consists off?
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
what is ROS?
1) ROS – review of systems: Dr’s examination, concentrating on most relevant areas and recording both positive and negative findings
what is O/E ?
1) O/E – on examination: General info on pt appearance
- E.g. pale, sweaty
what is JACCOL?
jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy
describe how cardiovascular information is documented.
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
describe how respiratory system information is documented.
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
describe how Gastrointestinal system information is documented.
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
what 7 things do you examine during the thorough examinations part of clerking in ?
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)
what occurs after the whole clerking in process?
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
