sukhs
Forum Senior
Topics: 19
Posts: 202
|
hi cs people
can anyone plz tell me wheher we can write in bullets form in the patient notes...
i mean :
1).pain abdo since 3weeks
.constant
.radiating to back
.sharp in quality
.aggravated by lying down
.relieved wih stooping foreward
2).nausea vomittins since 1 day
OR
we have to write patient is experiencing pain in he abdo since 3 weeks,constant in nature,sharp in quality,radiated to the back,aggravated by lying and relieved by stooping foreward....etc etc..
hope i made sense...but i really wanted to know whether we can use the 1st format to wrie the pt. notes
thanks
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| sukhs
Forum Senior
Topics: 19
Posts: 202
|
anyone?
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| arlete
Attending in 2012!!!!!
Topics: 43
Posts: 3,062
|
You can do either one.
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| sukhs
Forum Senior
Topics: 19
Posts: 202
|
Thanks a lot arlete...may i ask u which one do you recommend?
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| arlete
Attending in 2012!!!!!
Topics: 43
Posts: 3,062
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I like the narrative form. You don't waste space.
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| sukhs
Forum Senior
Topics: 19
Posts: 202
|
 okay..thanks arlete
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Everyone works equally hard.....God alone decides the reward...
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| arlete
Attending in 2012!!!!!
Topics: 43
Posts: 3,062
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| anp
Forum Newbie
Topics: 6
Posts: 46
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U have to write the full history -( complain-origin duration progres, severity etc, past medical history, family history, smoking etc,drug allergies, sexual history,gynaec history for females)in a limited space as is shown in the usmle site sample pt note.So if u write bullets for complain only u will not have enough space.I wrote in a sentence format. But i wrote Family history, social history, Past medical history as bullet.While practising pt note try using the usmle abbreviations-they are space savers.
I used-
HPI- Back pain X days,write description of pain ,ODP etc
PMH-
FH-
SH-
Menstrual history-
NKDA/ Allergic to sulphas
Physical exam-
Vitals- WNL /write which is abnormal
HEENT-If relevant to case
PERLA- , EOM- (if relevant to case)
Chest-
Heart-
Abd-
Neuro-
Ext-(If relevant)
Edited by anp on 02/02/08 - 05:40 PM
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| farnsworth
Forum Newbie
Topics: 0
Posts: 165
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the approach used by anp was the one I used and it worked out well. Actually: this is format I used to write PNs
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