medical notes Flashcards
why keep medical notes?
reminder - diagnosis or what needs to be done
communications - between healthcare professionals
medicolegal document - in case of civil/criminal action by a patient or their representative
who can write medical notes?
- Doctors
- Nurses
- Speacilst nurse
- OT/ PT/ SW / SALT
- Pharmacist
what information is contained in a nursing notes?
Admission details- next of kin, social situation
Care plans (usually standardised) - e.g. pressure sores, nutrition, etc.
Observations charts- TPR, SaO2, stools, fluid balance, food, etc.
Daily progress- care given, meds, eating
Discharge information
what does patients medical notes consist of?
past and current : Admission form Ambulance form / GP referral Clerking in & progress Investigations, diagnosis, treatment, monitoring Discharge prescription Other stuff – charts, results, letters
how is medical notes stored?
Electronic – several different systems in use!
Paper - Split into 2 halves
Left = past & current admission details
Right = results, letters, charts etc.
what does clearking in consists of?
1) General info
- Name, age, gender, admission route (GP, BIBA *brought in by ambulance)
2) PC or C/O (Presenting complaint or “complaining of”)
-Symptoms leading to admission e.g. CP (chest pain), SOB
off legs - elderly patients
3)HPC - history of presenting complaint
- More detailed info regarding PC, e.g. when problem started,
worsening/relieving factors action taken already, investigations done etc.
4) PMH – past medical history
- Medical/surgical problems, previous admissions
- Includes chronic diseases (MJTHREADS) ˚ = no/absent
5) DH or DHx – drug history
6) review of system
7) Ix – investigations
- Chest x-ray (CXR), abdominal x-ray (AXR), computerised tomography (CT)
8) Imp – impression / diagnosis (Dx )
- Provisional diagnosis (if several possibilities = differential diagnosis DDx or )
9) Plan – is admission required?
- Further tests/investigations needed
- Initial treatment
6) SH – social history
- Occupation, marital status, home circumstances (carers?), smoking, alcohol
7)FH – family history
MJTHREADS
M: myocardial infarction J: jaundice T: tuberculosis H: hypertension R: Rheumatic fever E: Epilepsy A: asthma D: diabetes S: stroke
what is review of systems
occurs after clerking
ROS – review of systems
-Dr’s examination, concentrating on most relevant areas and recording both
positive and negative findings
O/E – on examination
-General info on patient’s appearance, E.g. pale, sweaty
JACCOL – jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy
- CVD
- respiratory
- GIT
- CNS
- peripheral
- Orthopedic
what is checked in the cvd system
- HR and pulse
- Blood pressure
- jugular venous pressure
- heart sound
what is checked of the respiratory system
-respiration rate
-shortness of breath
-crepitation - crackle noises from heart or CLEAR (lungs with a line in it)
air entry
what is checked of the GI/GIT
- tenderness, pain or swelling in the lower abdomen
- bowel sounds
- bowel movement
what is checked of the CNS?
CNS – central nervous system
Alertness, Glasgow coma scale (GCS)
Test nerve function (e.g. stroke)
what is checked of the PNS
PNS – peripheral nervous system
E.g. numbness in hands/feet
what is checked of the orthopaedics section?
Ortho – orthopaedics (bones /joints)
Fractures (#), swelling etc.
whats happens afterwards?
Post-take ward round (PTWR) - further treatment plans made
Follow up - if necessary and progress noted
