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Documentation


Document, document, document!

What to document


Clinical notes do not need to be exhaustive. To give an adequate picture of the clinical situation, the following information may be necessary:
  • patient, source of the information, date and time
  • relevant history and physical findings
    • positive findings
    • important negative findings
  • conclusions
    • working, differential, and final diagnosis
  • plan of action
    • investigations, consultations, treatment, follow-up
    • rationale for the plan
  • information given to patient (or substitute decision maker [SDM
    Substitute decision maker (SDM):  A person who is legally authorized to make decisions on behalf of the patient. This authority may be granted by the patient himself or herself with a legal document such as an advance medical directive, by legislation in each province/territory or by the courts.
    ])
    • verbal or written instructions
    • questions asked and responses given
    • apparent understanding, consent
    • any disagreement or refusal of care
  • signature of writer and position (trainee level)

Special notations

Handover
When transferring care for the evening, the weekend, a vacation or any other reason, remember that the person assuming responsibility doesn't have your depth of knowledge about the patient's condition.

Provide information about the following:
  • what you expect to happen
  • any pending investigations
  • any pending consultations or reports
  • any unresolved medical or social issues (e.g. family concerns)
  • what you are worried about and perhaps suggestions for what should be done if your concerns occur
  • plans for future care

Clearly document who will be taking responsibility and when (i.e. start and end times, and dates).

Discharge summaries
At discharge, it is important to document the following:
  • the course in hospital, including treatments and complications or intercurrent problems
    • who was consulted and actions taken in response
    • investigations done and actions taken
  • investigations
    • with results pending
    • to be done after discharge and who is responsible for ordering these
    • who will be responsible for follow-up of those results
  • follow-up plans
    • what, when, who
    • discharge instructions
  • action taken to make relevant persons aware of the plans