Chart Keeping in Clinic
Clinic Record
Keeping
The main purpose of a
clinic encounter note is to RECORD AND COMMUNICATE the findings from the
complaint, H&P, and the diagnostic reasoning, conclusion, and plans drawn
from each patient encounter. These documents, along with others, will be
included in the patient's hospital medical record. In order to efficiently and
effectively communicate with other providers through your charts, it is always
important to keep in mind that all notes should be WELL ORGANIZED, CONCISE, and
CONVEY CLEARLY the observations and the thought process that led you to your
conclusion and plan. Always
avoid carrying over unrefreshed "cut and pasted" sections from note
to note. “Run-on” notes
that goes way too long may impair the ability of others to understand what
actually is going on with the patient, aim to limit your f/u notes to 1 page
WebCIS small font.
The Standard AIM
note template (aim for length of 1 page small font, 3 pages is WAY too long and
likely reflect unprocessed data)
•
Note
Label/header (name, MRN, emergency contact info; AIM initial visit or follow up
visit)
•
Problem
List (must be reviewed and “weeded” at every visit, synthesize the problems as
several may actually be related to one condition)
•
Active
•
Inactive
(PMHX/PSurgHX)
•
CC/HPI/ROS (interim hx)
•
Med
Allergy
•
Updated
Med List (Meds List reconciled and updated at every visit. Do bottle checks!!!
Do not just copy and paste)
•
FmHx
•
SocHx
•
Physical
Exam
•
Data
(must be interpreted and not pasted in)
•
Assessment/Plan
(one line summary of encounter at top. Then list problems and plan. Do not list
by organ system)
•
Health
Maintenance
Take
a thoughtful approach to the assessment/formulation section and use it to
provide a big picture view of what is going on with the patient. Assessment and
plans should be summarized BY PROBLEM (not organ system). Problems may be
diagnosed diseases/syndromes, or symptoms, symptom complexes, or abnormalities
from the exam, labs, or imaging. If you
prescribe a medication or order a test, be sure to write out your reasoning and
plan for that particular approach.
Updating health maintenance and preventive measures should always be
part of you’re A/P. Click on our website’s note samples (look under
charting) to see samples of different visit formats.
In addition to the
official medical records, the intern will be provided his/her own binder for
organizing his/her clinic paperwork. This binder is kept in the closet in
your home Firm (near the back door lockers), and allows you to maintain a personal
on-site file for a shadow clinic records or test results, outside paperwork, or
copies of your favorite patient hand outs.
Click on the
notes below to see samples of different visit formats
·
Sample
Note - Follow Up Visit
·
Sample
Note - Complex New Patient
·
Sample
Note - Complex Follow Up Patient
Patient Profile Sheet -
helps you to organize vital patient information and organize health maintenance
tests
Chart Review Exercise with Dr. N Chang
·
Ambulatory Chart
Review template – Download these sheets for the Chart Review Exercise
during your OPD block. During that exercise, we will evaluate how well your
charts fulfill the intentions of clear communication and quality
assurance.
·
Diabetes QA Work Sheet
– for Chart Review Exercise during OPD block.