Introduction/Allergy/Disposition
What is the importance of documenting allergies in the medical chart?
What is important to note about the the allergy?
To prevent administration of contraindicated medications and avoid adverse reactions
Include the specific medication and the type of allergic reaction experienced - eg. rash, breathing issues etc.
What should be documented in the past medical history section?
Previous diagnoses, surgeries, hospitalizations, and ongoing medical conditions
What does the "presenting complaint" section of a medical chart describe?
The primary symptoms and issues that brought the patient to seek medical care
How should the patients medication use be recorded?
List current medications:
type (inhalation, tablet etc)
Name of medication
dosages
when/how often eg. 1+0+1+0
and the conditions they were prescribed for
Name the 5 vital signs that should be recorded
Vital signs, general appearance, and a review of major systems
Record blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation
What information should be included in the introduction?
Age, gender, where referral came from (i.e. emergency room, family physician), reason for admission
How should a history of surgeries be documented?
Include the date, hospital, type of surgery, reason, and any complications or outcomes
How should the patient's chief complaint be documented?
As a concise statement summarizing the primary issue in the patient's own words
How should lifestyle factors like smoking and drinking be recorded in the chart?
Detailed documentation of habits like smoking (pack year: 20 cig. per day for 1 year= 1 pack year), alcohol consumption, amount per day/week and what, drug use.
age, gender, disease the pt. is known with, a summary of the patient's condition, primary diagnosis, and differential diagnoses
Give 3 examples of a family disposition that should be noted.
Diabetes, hypertension, heart disease, cancer, or autoimmune diseases, astma
How should a patient's exposure to occupational hazards be documented?
Note the type of hazard, duration of exposure, and any protective measures taken
What additional details should be included about the presenting complaint?
Characteristics of the symptoms, including onset, duration progression, location, and factors that alleviate or exacerbate the symptoms. intensity:VAS,
Marital status, living situation, occupation, and support system. self reliant or home nurse? use of a walker?
Why is it important to document the supervising physician and the medical student involved in the case?
Ensures accountability and provides a record of who was involved in the patient's care
Why is it important to document family history in the dispositions section?
It helps identify genetic or hereditary conditions that may predispose the patient to certain diseases
Potential contact with infectious agents, toxins, or environmental factors
What is the significance of documenting the patient’s initial self-treatment or actions taken?
Provides insight into the effectiveness of interventions and potential misdiagnoses or complications
Why is it important to document over-the-counter and herbal medications?
They can interact with prescription medications and affect the patient's condition
How should patient education and informed consent be documented?
Record the information provided to the patient and their understanding/agreement to the plan
How can family dispositions influence a patient's diagnosis and treatment plan?
They can guide screening, preventive measures, and early interventions for at-risk conditions
Give 4 examples of an exposure that should be documented.
Recent travel/hospitalization i foreign country, contact with sick individuals og animals, or exposure to hazardous substances (asbestos, dust, radiation), sexual risk behaviour.
Which 6 organsystems must always be asked about under: all organsystems?
Nervous system:
Cardiovascular:
Respiratory:
Gastro-intestinal:
Urogenital:
Musculoskeletal:
Why is it important to document the patient's support system?
It helps assess the patient's resources and ability to follow through with the treatment plan - and let us take the right precautions as physicians
(EXTRA INFO): How does documenting the conclusion help in patient care continuity?
Proposed tests, treatments, follow-up appointments, and patient education
It provides a clear, concise summary for other healthcare providers to understand and continue the care plan (most colleagues just read, introduction, presenting complaint and conclusion+plan)