Introduction to medical notes Flashcards
1
Q
Why do we have medical notes?
A
- Centralised documentation of all all things to do with patient care
- Communication - between health care professionals
- Medicolegal documents - in case of civil/criminal action
- All health care professionals can add to it
2
Q
Name the three main points when notes are added to a patients medical notes
A
3
Q
What are ‘clerking notes’
A
- Presenting complaint (PC)
- Past medical history (PMHx)
- Allergies
- Social history (SHx)
- Drug history (DHx)
- History of presenting complant (HPC) - more dtail of PC e.g. when it started, got worse etc.
- Medical/surgical problems
- Chronic diseases
4
Q
What is included in nursing notes
A
5
Q
What is included in pharmaceutical notes?
A
6
Q
How are notes kept?
A
- Mainly electronic - EPMA, EPIC or CERNER
7
Q
What is the RoS and the O/E section in medical notes
A
- RoS is split into areas like CVS, resp, CNS, GI/GIT, PNS or ortho
- For example RoS for resp will include: shortness of breath SOB, Air entry AE, Respiration rate RR
8
Q
What does Ix, Imp/Dx and Plan stand for
A
- Ix is investigations: e.g. CT or an ECG
- Imp or Dx is impression/diagnosis
- Plan is admission required? - further tests, initial treatment
9
Q
What does ‘post clerking’ include
A
- Post-take ward round PTWR
- Patient reviewed by senior doctor
- Further treatment plan made
- Follow up is later on when patient is visited and progress is noted
