05-22-2008, 07:06 AM
ok when you write patien note follow this order 1) D/D and Diagnostic test 2) physical 3)HX
when you write DD write from most probable to least, and for diagnostics test most simple to complex.. first write down forbidden physical exam followed by relevent test
Write the CC in patients own word and for HPI always use medical terms. for example if the patient say burning urination,shortness of breath, removal of appendix just write on patient not as dysuria, dyspnea, appendectomy ,polypectomy... always use medical terms...in HPI
dont use complete sentences and waste time.. just write 28 yo F patient c/o pain in middle of chest for last 2 hours, constant,sharp 8/10, gradually progressive,nonradiatin,no alleviating aggravating factoers. Has h/o nausea vomiting,, blah blah.. SO DONT WRITE FULL SENTENCES
USE abbreviations as much as possible
Write all positives and if you have time towards the end write down the negatives keeping thr differentials in mind.
for example for a case fatigue.. you need to write no h/o cold intolerence,constipation,skin changes, change in weight appettie, bowel or bladder..
(here you need to think of DD hypothyroidism and cancer)
for physical write down all postives and negatives. in the above case you need to mention
HEENT: no pallor, NECK: no thyromegaly, just mention about chest,heart,and abdomen, and ext: DTR
Finally to get good score in patient note you must have taken a good history and noted evrything briefly on your clipboard.. then you can easily transfer them to PN (so practice this part very well its very important)
go through all case in FA and UW and find out what POSITVES AND NEGATIVES that you have to wirte in the hisotry and physical exam
hope it helps i am not good at patient note so thats all i can advis you for the time being
when you write DD write from most probable to least, and for diagnostics test most simple to complex.. first write down forbidden physical exam followed by relevent test
Write the CC in patients own word and for HPI always use medical terms. for example if the patient say burning urination,shortness of breath, removal of appendix just write on patient not as dysuria, dyspnea, appendectomy ,polypectomy... always use medical terms...in HPI
dont use complete sentences and waste time.. just write 28 yo F patient c/o pain in middle of chest for last 2 hours, constant,sharp 8/10, gradually progressive,nonradiatin,no alleviating aggravating factoers. Has h/o nausea vomiting,, blah blah.. SO DONT WRITE FULL SENTENCES
USE abbreviations as much as possible
Write all positives and if you have time towards the end write down the negatives keeping thr differentials in mind.
for example for a case fatigue.. you need to write no h/o cold intolerence,constipation,skin changes, change in weight appettie, bowel or bladder..
(here you need to think of DD hypothyroidism and cancer)
for physical write down all postives and negatives. in the above case you need to mention
HEENT: no pallor, NECK: no thyromegaly, just mention about chest,heart,and abdomen, and ext: DTR
Finally to get good score in patient note you must have taken a good history and noted evrything briefly on your clipboard.. then you can easily transfer them to PN (so practice this part very well its very important)
go through all case in FA and UW and find out what POSITVES AND NEGATIVES that you have to wirte in the hisotry and physical exam
hope it helps i am not good at patient note so thats all i can advis you for the time being