You should write the record as soon as possible, before the data fade from your memory. At first, you will probably prefer to take notes when talking with the patient. As you gain experience, however, work toward recording the Present Illness, the Past Medical History, the Family History, the Personal and Social History, and the Review of Systems in final form during the interview. Leave spaces for filling in details later. During the physical examination, make note immediately of specific measurements, such as blood pressure and heart rate. On the other hand, recording multiple items interrupts the flow of the examination, and you will soon learn to remember your findings and record them after you have finished.
Several key features distinguish a clear and well-organized written record. Pay special attention to the order and the degree of detail as you review the record below and later when you construct your own write-ups. Remember that if handwritten, a good record is always legible!
The order should be consistent and obvious so that future readers, including yourself, can easily find specific points of information. Keep items of history in the history, for example, and do not let them stray into the physical examination. Offset your headings and make them clear by using indentations and spacing to accent your organization. Create emphasis by using asterisks and underlines for important points. Arrange the present illness in chronologic order, starting with the current episode and then filling in the relevant background information. If a patient with long-standing diabetes is hospitalized in a coma, for example, begin with the events leading up to the coma and then summarize the past history of the patient's diabetes.
The degree of detail is also a challenge. It should be pertinent to the subject or problem but not redundant. Review the record of Mrs. N, then turn to the checklist in Chapter 18 on pp._. Decide if you think the order and detail included meet the standards of a good medical record.
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