Whether you are seeing a patient in an outpatient clinic, the emergency department or in general practice, the ability to engage in a medical consultation is vital to clinical practice. The medical consultation is your basic tool and good communication is king. Rather, the following are some tricks and suggestions that may make you a better communicator.
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It is a means of communicating information to all providers who are involved in the care of a particular patient. It allows students and house staff an opportunity to demonstrate their ability to accumulate historical and examination based information, make use of their medical fund of knowledge, and derive a logical plan of attack.
It is an important medical-legal document. An instrument designed to torture Medical Students and Interns. Meant to cover unrelated bits of historical information.
Should neither require the killing of more then one tree nor the use of more then one pen to write! Knowing what to include and what to leave out will be largely dependent on experience and your understanding of illness and pathophysiology. If, for example, you were unaware that chest pain is commonly associated with coronary artery disease, you would be unlikely to mention other coronary risk-factors when writing the history.
Until you gain experience, your write-ups will be somewhat poorly focused. Not to worry; this will change with time and exposure. Several sample student write-ups can be found at the end of this section. One sentence that covers the dominant reason s for hospitalization.
Smith is a 70 year old male admitted for evaluation of increasing chest pain. The HPI should provide enough information without being too inclusive.
Events that occurred after arrival are covered in a separate summary paragraph that follows the pre-hospital history. Some HPIs are rather straight forward.
If, for example, you are describing the course of an otherwise healthy 20 year old who presents with 3 days of cough, fever, and shortness of breath, you can focus on that time frame alone.
It gets a bit more tricky when writing up patients with pre-existing illness es or a chronic, relapsing problem.
In such cases, it is important to give relevant past history "up front," as having an awareness of this data will provide contextual information that will allow the reader to better understand the most recent complaint. If, for example, a patient with a long history of coronary artery disease presents with chest pain and shortness of breath, it might be written as follows: S is a 70 yr old male with known coronary artery disease who is: This represented a significant change in his anginal pattern, which is normally characterized as mild discomfort which occurs after walking vigorously for 8 or 9 blocks.
In addition, 1 day prior to admission, the pain briefly occurred while the patient was reading a book. He has also noted swelling in his legs over this same time period and has awakened several times in the middle of the night, gasping for breath. In order to breathe comfortably at night, Mr.
S now requires the use of 3 pillows, whereas in the past he was always able to lie flat on his back without difficulty. S is known to have poorly controlled diabetes and hypertension. He denies fevers, chills, cough, wheezing, nausea vomiting or other complaints. From a purely mechanical standpoint, note that historical information can be presented as a list in the case of Mr.Consult Note Template On the internal medicine service, you may be consulted (asked) by other services such as emergency or surgery to evaluate a patient and either give recommendations, or to see whether this patient should be admitted (and therefore cared for) up .
SAMPLE DOCUMENTATION TEMPLATES UPHS – Department of Medicine Initial Hospital Visit/Inpatient Consult Note leslutinsduphoenix.com How to Write a Good Consult Note: Tips and Template October 10, rose As a doctor, you may need to provide a consult note that helps other physicians understand a patient’s medical history and your recommended course of treatment.
Format of Dictated Consult Notes.
Patient Identification Physician Requesting Consult. Reason for Consultation. Impressions. Recommendations. H&P. History of Present Illness, allergies Present Illness Past History Family Medical History/Social History.
Review of Systems. Physical Examination including Vital Signs. Below is an explanation of how to do a Consult. Hence, your CC for the cardiology team should be: "Acute MI". If you want to be more descriptive you could write: "Anemia induced Acute MI".
Leave the past medical history to the past medical history section! Advice on how to succeed in medical school, apply for residency programs, and become a doctor! Pages. Home; About; The original post on how to write a SOAP note for a patient was intended to be a definitive post on how to write this daily note that ever.