ART-OF-MEDICAL-Documentation-sent.pptx k m

1. ART OF MEDICAL Documentation DR. SALMA ELAGEL د. سالمه العاقل MBBS (Tripoli university- Libya) MMED (University Malaya- Malaysia) MRCPI (Ireland) ART OF MEDICAL Documentation DR. SALMA ELAGEL د. سالمه العاقل

2. CONGRATULATIONS 2010-2019 BATCH ( 38)

3. Education is not the learning of facts, but the training of the mind

4. *if it isn't documented, you didn't do it * We should be training you to become doctor not a clerk. Think. Don't just follow order!"

5. The topic Outlines Written communication Understanding the system. Patient’s history and examination notes. Admission note. Follow up notes. Writing drug prescription. Requesting Imaging or procedure. Procedure notes. Referral note (call paper ). Referral letter.

6. Types of communication Verbal Written Body language

7. The written communication transmission of information Effective Written Communication : A+B+C A Accuracy B Brevity ( K.I.S.S: Keep It Short and Simple ) C Clarity Use words that are easy to understand Always keep your goal in mind always remember to look at your writing from the perspective of the reader .(avoid un approved abbreviations)

8. Medical notes Medical notes are a collection of information on a patient that includes any relevant history the patient’s current problem and progress. the diagnosis and details of any interventions . The notes are legal documents .

9. Understanding the system Observation ward Causality (ED) F ilter/Triage Resuscitation Room Admission Ward OPD Other ward (Transfer) ICU During admission *Procedure *Other team (Call) *Transfer Discharge

10. Admission Def. allowing the patient to stay in hospital for observation, investigations and treatment of the disease

11. Patient’s history & examination notes SOAP S O A P

12. Communicate with the patient Once you completed admission note and document the possible diagnosis with the management plan; you should communicate with the patien t and inform him/her regarding the plan.

13. Admission note /Opening statement 10 years old boy with underlying Trisomy 21 and Congenital Heart Disease. 28 years old lady, G ravida 3 para 2 at 27 weeks of gestation referred for high BP 30 years old gentleman . with No known chronic medical illness . (NKMI) 50 years old lady with underlying poorly controlled DM for 20 years Know the requirement A surgeon + chronic medical illness (anti coagulant/ anti plt ?) Physician + detailed surgical history (medical admission) O/G + detailed medical Hx THE USUAL STEPS: History , physical examination, investigations, diagnosis and management .

14. Follow up notes

15. Follow up patient’s review What’s is a REVIEW? (patient’s update ?) purpose? To get to know progress of their diseases, updates their latest investigation result. check whether any new problem arises and manage it. NOTE: Patient is not just managed for a day. Not only during the day that you review the patient. Management starts from the first clerking until you give the discharge paper hence the daily review is a must.

16. Follow up patient’s review Documentation Process? SOAP again Time and date Type of review; morning follow up/ grand rounds/post transfer in r/v, postnatal r/v, post operative r/v (give a title for your review) Patient's name and age ? What Day of admission? Comorbid illness /underlying diseases. Diagnosis/Current Issue ( Presenting complaints (in summary, that supports your diagnosis ) + management progress for the disease. List of current issues/problem (active diseases that’s keeping them in the ward ( write short explanation regarding each problem ) Assessment on the patient’s overall condition & progress of their symptoms O/E Vital sign + specific examination Important investigation results related to the diagnosis+ significant abnormal inx plan

17. What do you do after follow up? Carry out the plan: 1. Documentation review and order the requested investigations. 2. Order the medication and update the treatment chart. 3. Request imaging (you need to request it from the respected team)/ e.g : CT scan from radiologist. 4. Trace previous investigation results. 5. take blood /simple procedure / assist the SHO in procedures/ write calls and referrals/write discharge summary. learn from other staff what ever u can.

18. Transfer to or within the same hospital the requested physician (who order it?) Inform the patient and family Inform ward in charge or another unit Complete patient’s documents Arrangement for transportation (to another hospital) Hand over the case notes and treatment chart.

19. Writing the prescription Know the restricted medications Pt name and age Diagnosis? Use generic name Drug dose. Route . Frequency. Duration Block the open space Sign your name Date. Clear handwriting

20. Requesting investigation, Imaging or procedure Fill up the form Patient’s details Reason for the request

21. Procedure note Date and time Details of the procedure Patient’s clinical condition Any immediate complications Advice and plan (post procedure) example : if you took sample >>>> sample? where and for what to send? observation dressing analgesia Follow up

22. Referral note (Call) Date and time Pt data Urgency of referral ? Reason for referral with justification? Send the call form

23. Referral letter

24. Referral letter Pt data Diagnosis Greeting Specialty required/ urgency Polite opening statement Description of the problem including examination and significant inx findings. Reason for the referral The medical background and relevant family history. Expected response/ patient knowledge. Thank you Doctor name, signature

25. Thank you