Understanding Medical Notes

Question 1

Why do we keep medical notes?

Answer 1

1. Reminder- Diagnosis, what needs to be done
2. Communication- between healthcare professionals
3. Medicolegal document- incase of civil or criminal action by a patient or their representative

Question 2

Who writes in the medical notes?

Answer 2

1. Doctor- finds out whats going on, who’s given the care
2. Nurse- 2 to 3 shifts, discharging the patient, giving the medicine
3. Specialist Nurse- Review patients applications and write their recommendations
4. Speech Language
5. Occupational Therapists- patients can’t swallow medicines
6. Pharmacists- Sort out drug boxes, medication they need when discharged and correct doses

Question 3

What is in the nursing notes?

Answer 3

1. Admission details- next of kin, social situation
2. Care plans- pressure sores, nutrition
3. Observation charts- monitored several times a day, SaO2 (asthma), stools (charts for different poo), fluid balance (vomitting)
4. Daily progress- care given, meds, eating
5. Discharge information

Question 4

Describe what is written on the medical notes?

Answer 4

1. Admission form
2. Ambulance form / GP referral
3. Clerking in and progress
4. Investigations, diagnosis, treatment and monitoring
5. Discharge prescription
   Other Stuff- charts, results, letters

Question 5

What is clerking in, who is it written by and is it reliable?

Answer 5

1. The first admission details made:
   History, examinations, investigations, management
2. Usually written by HO/F1 (House officer, pre-reg doctor) or SHO/F2 (Senior House officer, 2 years doctor)
3. Available information quite limited
4. Quality variable

Question 6

What information is normally obtained from clerking in? (7 points)

Answer 6

1. General information: Name, age, gender, admission route (GP, BIBA (bought in by ambulance))
2. PC or C/O
   - presenting complaint or complaining of
   - symptoms leading to admission e.g. CP, SOB, unwell, off legs, collapse, confusion, fall
3. History of presenting complaint- more detailed regarding the PC: when did the problem start, worsening and relieving factors, action taken already, investigations done
4. Past Medication History- medical, surgical problems, previous admissions
   also includes chronic diseases (MJTHREADS)
   - dot on top of one of those means disease is present
5. DH or DHX- Drug History
   - Current and recently stopped medication
   - Include dose, frequency and indication
   - ADRs, intolerances and allergies
   - Often inaccurate/incomplete especially OTC, creams, inhalers, eyedrops, herbal preps
   - Should match PMH- missing medicines, cautions and contra-indications
6. Social History- Occupation (high stressed job), marital status, home circumstances (carers), smoking, alcohol
7. Family History- Genetic illnesses, risk factors, example: heart disease, cancer etc.

Question 7

What is the ROS- review of system?

Answer 7

1. Dr’s examination that concentrates on the most relevant areas and records both positive and negative findings
2. An idea in mind of what is exactly happening

Question 8

What is the O/E- on examination?

Answer 8

General information on patients appearance whether they are “pale, sweaty, JACCOL (Jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy)”

Question 9

What does JACCOL stand for?

Answer 9

1. Jaundice- yellowing of eyes and skin due to liver
2. Anaemia- tired due to lack of red blood cells
3. Clubbing- swelling of fingers
4. Cyanosis- impaired blood flow, blue lips, not enough oxygen
5. Oedema- swollen ankles
6. Lymphadenopathy- enlarged lymph nodes and infections

Question 10

How are patients in the cardiovascular region examined when they come into the hospital?

Answer 10

1. Pulse
   - beats per minute (bpm) and regularity of beats
2. Jugular venous pressure (JVP)- lay back 45 degrees, higher pulse, higher level in neck
   - (->) Right arrow means normal
   - (upwards arrow) means raised
3. Blood Pressure (BP)
4. Heart sounds
   - I — II — O (wiggly and whooshing line represents values not closing properly)

Question 11

How are patients in the Respiratory system examined when they come into the hospital?

Answer 11

1. Respiration Rate (RR)
   - Breaths per minute
   - Picture of lungs with arrow across means chest is clear
   - Picture of lungs with x’s mean crepitations means crackling sounds due to infections or heart failure
2. Shortness of breath (SOB/SOBOE)
3. Air Entry (AE)- are both lungs working equally

Question 12

How are patients in the Gastrointestinal system examined when they come into the hospital?

Answer 12

1. Picture of a hexagon with a circle within it
2. Represents Tenderness, pain, swelling
3. Bowel Sounds (BS)
4. Bowel movements

Question 13

What specific things are done in the review of the systems to analyse the patient?

Answer 13

Checking of the Central Nervous System: 
- Alertness, Glasgow coma scale (GCS)
- Test Nerve Function
Peripheral nervous system
- numbness in hands or feet
- Ortho- orthopaedics (bones and joints) - fractures (#), swelling etc.

Question 14

What methods of investigation are used to find out about the patient? And what is done after they’ve obtained the information?

Answer 14

1. Chest xray (CXR), abdominal x ray (AXR), computerised tomography (CT), electrocardiogram (ECG)
2. Imp or Dx or delta triangle are used to show impression and the provisional diagnosis or DDX or Delta Delta shown for more possibilities
3. They then plan if more admission is required and a further treatment plan is made and patient visited as needed and progress is noted