Note-keeping Flashcards
What is involved in patient assessments
Find out info about patient
Watch patients perform tasks
Medical history
Builds a relationship
Forms a diagnosis
Allows treatment to be specific and correct
How to retrieve info in a clinical setting
Medical records
Patient
Family members or carers
Referrals
Inpatient info
Full medical records within trust
X-rays/scans
Referrals
Outpatient info
Full medical records within trust
X-rays/scans
Hospice or special school info
Limited to specific hospice or school
Some medical notes
Some history of patient
Care plans
Private practice info
May not have any extra info if patient referred themselves
What is the electronic notes system
Can be accessed by all clinical staff
Includes images, tests, theatre notes, appointments, assessments and personal data
System is dependent on trust
Can search patient name, NHS number and DOB
Why are patient notes documented
Legal requirement
Factual info
Permanent record
Justifies care provided
Enhances communication
Basis of patient note writing
Chronological order
Record factual info
Analysis can include opinion
Can use ‘patient quotes’
Title the entry
Date and time stamped
Completed within 24hrs of seeing patient
Sign, print name and profession
Limited abbreviations
What are SOAP notes
Subjective
Objective
Analysis/assessment
Plan
What is included in ‘subjective’ notes
Presenting condition
History of presenting condition
Past medical history
Drug history
Social history
Consent given
Time patient was seen
Who was present
What is included in ‘objective’ notes
Medical observations/vitals
Physical observation
Range of movement
Where is patient
Patients posture
Patients appearance
Any attachments
Specialist equipment
Patient environment
What is included in ‘analysis/assessment’ notes
What results mean
Diagnosis
Do results fit a condition
How was patient managed (justification)
Strength
Pain
Problem list
Goals
What is included in ‘plan’ notes
What is going to occur in different sessions
What can patient do outside of sessions
Can relate to assessment findings/analysis
Can be for family, other professionals or yourself
