Understanding Medical Notes Flashcards
Why write medical notes?
- Reminder - diagnosis, what need s to be done
- Communication - between healthcare prof.
- Medicolegal document - in case of civil/criminal action by patient or representative
Who writes them?
Doctors
Pharmacists
Nurses
Specialist Nurses
What Nursing notes?
Admission details Care plans Observation charts Daily progress Discharge Info
How are the notes set out?
Split into 2
Left - past and current admission details
Right - results, letters, charts
Centre - most current info
What is clerking in?
Admission details
usually written by HO (house officer) or SHO (senior house officer)
Limited info
What does HO mean?
History of…
OR
House officer
What does SHO mean?
Senior House Officer
Clerking In?
general info- name, age, gender, admission route
PC or C/O
Presenting complaint or complaining of .
Symptoms leading to admission
What does PC and C/O mean?
Presenting complaint
Complaining of…
What is HPC?
History of presenting complaint.
More detailed info - when problem started, action taken already
What is PMH?
Past Medical History
previous admission
includes chronic diseases
DH or DHx?
Drug History
Current and recently stopped meds
dose, freq, and indication
ADRs, allergies
Often incomplete esp OTC - creams, drops etc
SH?
Social History
Occupation, marital status, home circumstances (carers?), smoking, alcohol
FH?
Family History
Genetic illnesses, risk factors etc.
E.g. heart disease, cancer etc.
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 pt appearance
E.g. pale, sweaty
JACCOL – jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy
What does JACCOL mean?
jaundice, anaemia, clubbing, cyanosis, oedema, lymphadenopathy
Review of systems? (3)
CNS - Central nervous system e.g alterness
PNS - peripheral nervous system e.g numbness in hands/feet
Ortho - Orthopaedics
bones/joints - fractures
Ix?
Investigations
Chest x-ray (CXR)
Abdominal x-ray (AXR)
Imp?
Impression/Diagnosis (Dx/ or a trainagle
if several or differential diagnosis - DDx or 2 trainagles
Plan - is admission required?
Further tests needed
Initial treatment
PTWR?
Post take ward round
Patient reviewed by senior doctor
