Documentation and oral summary

Question 1

what are reasons for documenting

Answer 1

audit
research
quality assurance
only enduring version of the patient’s condition
good to refer back to
if not recorded- history/exam wasnt done
protection from legal challenges

Question 2

what are the basics of documentation

Answer 2

form of communication
audience is your colleagues
keeping it concise
must be legible
date and time entry- make a soon as
sign with your indicating role
patient identifying details are on every sheet
patient can ask to see any records

Question 3

what are admission histories

Answer 3

they take a standardised format that allows others reading it to quickly identify the piece of info they are seeking

Question 4

what is the reason for admission

Answer 4

clearly state why and when the patient has been admitted

Question 5

what is the order of documenting

Answer 5

reason for admission
HPC
Medication history
SH/FH
SE- document negatives
Examination
Summary
To-do list

Question 6

what are some important tips for oral summaries

Answer 6

think about
-what important features you want to get across
-differential diagnosis
-present negative info

Question 7

basics of oral summary

Answer 7

set the scene
expand on the reason for the admission
differential diagnosis
final sentence- care plan

Question 8

why is knowing hand dominance important

Answer 8

patient will be less incapacitated by an injury to the non-dominant hand