Understanding medical notes Flashcards
Why are medical notes kept
diagnosis
communication between healthcare professionals
medicolegal document in case of civil / criminal action by a patient or their representative
who is involved in taking medical notes
doctors
nurses
OT PT SW
Pharmacist
What is contained in the nursing notes
admission details care plans observations daily progress discharge information
What can be contained in medical notes
admission form ambulance form or gp referal clerking in & progress investigations, diagnosis, treatment, monitoring discharge prescription results charts letters
What are the two ways in which medical notes are kept
electronically paper
What is taken during clerking in
admission details general information presenting complaint / complaining of history of presenting complaint past medical history drug history social history family history
what is review of systems
doctors examination concentrating on most relevant areas and recording both positive and negative findings
what is oe mean
on examination, includes general information on patients appearance
what does hr mean
pulse in bpm
what does bp mena
blood pressur
what is jvp
jugluar venous pressure
what is HS
heart sounds
what is rr
breaths per minute
what is SOB/SOBOE
shortness of breath
what is AE
air entry
