Tuesday, October 14, 2008
reading notes
Obviously before treating a patient, reading their notes is one of the most important things to do. One thing I have often done in the past, especially if a patient has been admitted for a long time, was to glance over their history and pay the most attention to the newest issues at the end of the integrated notes. I have learnt on my prac at the moment, that taking the time to read the 'old notes' is just as important as the new ones. By just glancing over the patients older notes, you may miss important facts about surgerys, states of instability and their general pattern of treatment/management since admission. Although it takes a pretty long time to read notes (for me anyway) its so important to get an overview of how your patient has been going since their admission, no matter how long it is.
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2 comments:
I agree there, notes are great, you get all sorts of treatment ideas and when you can read them learn more about what sort of thing the doctors look for. I've found that the notes are also great to find out their religion (some religions may require same sex physios), country of birth (great when looking for the patient), age (good to know how long you feel you can spend with them), primary laguage spoken (you may need an interpreter) and for RITH any risks that you could face at their home such as massive dogs or family members who sometimes become defensive.
having said that though, i dont think we should be so reliant on previous entries. As long as time is suffienct, most of the information we seek we should be able to obtain from the assessment ourselves. I have felt myself on a number of occasions unintentionally narrowing my vision after reading notes. I think i much prefer to organise the information myself and then gather additional required info from previous entries
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