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Clinical Documentation

From Mediwikis
Stethoscope Notes.jpg

Clinical documentation is required for every patient encounter, as a record of what has occurred for yourself and the other team members, and in the unlikely event of a medico-legal issue. Your skills in writing in patient notes may be assessed during an OSCE or WRISKE, so practice whenever you get the chance!

Required elements

  • Write in black ink

On every page

  • Every page should have the name of the hospital on and the name of the consultant looking after the patient
  • Make sure that every page you write on has the correct patient details on in capital letters:
    • Name
    • DOB
    • Unique Patient Identifier

At the start of each entry

  • Start the entry by putting the Time, Date, and purpose of review, e.g. "09:30 12/12/14 Ward Round Dr Smith"
  • Then put your name and role e.g. Third Year Medical Student and underline it
  • Put down the information required clearly and concisely, use bullet points, make it as easy to read as you can

At the end of each entry

  • Your signature
  • Name in block capitals
  • Your grade
  • Your GMC number (when you get it)

Structured Documentation

SOCRATES

For pain histories, but applicable to other complaints

  • Site
  • Onset
  • Character
  • Radiation
  • Associated Symptoms
  • Time course
  • Exacerbating factors
  • Severity (out of ten)

SOAP

  • Subjective
    • Chief Complaint
    • History of Presenting Complaint
    • SOCRATES
  • Objective
    • Vital signs- Respiratory rate, pulse, O2 saturations, weight, temperature
    • Physical examination findings
    • Laboratory tests
    • Medication list
  • Assessment
    • Impression or summary of the patients problems
    • Differential diagnoses
  • Plan
    • Clinical plan to treat the patient's complaints- investigations, treatment, referral

Hints and Tips

  • If you need to make a correction, put a single line through your words and initial the correction. Do not cross it out to the point of illegibility- this looks suspicious
  • Bullet points are useful for conveying information clearly and quickly
  • Write objective facts, never humour or personal opinion. It is acceptable to document the patient's mood e.g. euthymic!
  • Think about the impression your notes give to those reading them, which may include your consultant or even the patient- a scrawl is quick, but does not complement you!