Overview of Medical Notes Flashcards
Why do we take notes?
- Increase quality of patient care
- Less redundancy
- Physician reimbursement
- Legal testimony
- Communication between providers
- Scientific knowledge and research
What to document?
Only things you have personally witnessed or verify through credible source, cite outside sources
What are the parts of a medical note?
SOAP
- Subjective
- Objective
- Assessment
- Plan
Chief Complaint
Subjective
- State in the patients own words
- Symptoms and goals ARE chief complaints, DON’T use diagnosis
- Only use medical terms if patient uses them
History of Present Illness (HPI)
Subjective
- Who, Age, Gender, History, Where, What
- Pertinent past medical history: Known diagnosis and Obstetric History
- Record in Chronological Order
- Use Abbreviations sparingly
- Patients own words
- Problem pertinent ROS may be included
- Document limitations: Dementia, Alcohol intoxication, Language barrier
Family History
Subjective
- Includes problems in immediate family and direct lineage (Specify maternal/paternal)
- Living? How and when did they die?
- Depending on disease inheritance we may need more complete history (Aunts, Uncles, cousins)
Social History
Subjective
- Alcohol, tabacco, drugs (start and quit)
- Employment, exposures, exercise
- Habits, diet, relationships
- Religion (as it relates to treatment)
- Children history more difficult: Passive exposure, daycare, sports, activity level
Past Medical/Surgical History (including obstetric)
Subjective
- Known medical diagnosis
- Surgeries (date and indication)
- Previous hospitalizations
- Childhood illness and immunizations
- Include alternative medicine treatments
- Obstetric History (pregs/outcome)
Medications/Allergies
Subjective
- Current and recent medications
- Include other herbal supplements
- Allergies can be to food, drugs or environmental exposures (list type of reaction if known)
Review of symptoms
Subjective
- Record positive/negative for each symptom
- Only recent symptoms (chronic problems => HPI)
- “All other systems negative” Circumstantial
Physical Examination
Objective
- Include general impression of patient
- VITAL SIGNS
- Serial examinations may go in department course
Special Tests & Procedures
Objective
- Name of procedure and indication
- Informed consent
- Individual performing procedure
- Location on body
- Specific equipment used
- General Technique
- Complications
- Outcome of procedure
Lab Results
Objective
- May be in MDM
- LIst name of investigation followed by: Pertinent negatives, Positive findings, “Otherwise WNL” (within in normal limits)
Radiologic Studies
Objective
- Give full name of study with modifiers
- Include radiologist’s name
- Use the “Impression” given on the report
- Include details when relevant
Department course
Objective/Assessment
- May be combined with MDM
- Include tine when actions were taken and patient response
- List preventative measures
- Especially important in trauma/critical care
Summarize all subjective & objective information to support actions and treatments prescribed
Assessment
Analysis of signs, symptoms, physical examination, and diagnostic findings
Assessment
Justification for actions in diagnosis and treatment of illness
Assessment
Medical Decision Making (MDM)
Assessment
Medications
Plan
Further procedures and interventions
Plan
Further diagnostic studies
Plan
Consultation
Plan
Patient instructions: Admit, Discharge, Transfer
Plan
