Documentation
Importance of chart notation
The purpose is to communicate with all health workers involved with the patient
and as a reminder to yourself. One should make notes any time the patient is
seen (why did you see this patient and what did you see and do?). Notes can
be brief.
Consider the need to provide details of the following when communicating with
the patient and other members of the health care team:
- Patient’s name and identifying hospital number;
- Findings, treatment and investigations instituted and assessment of interventions
given to the patient;
- Document specific discussions particularly with regard to wishes regarding
operative interventions, treatment or genetic considerations.
Writing a referral
Date
Referring Doctors Name and Address
Patient’s name
Contact details
Ask that the medical practitioner see the patient, express the relative urgency
and the problem in a “nut shell”. Provide a brief history of the problem, what
you have done, the investigations and treatment. Provide relevant history including
present medications.
Thankyou
Prescribing
It is important to never guess. Take that extra moment to review appropriate
dose, timing and side-effects.
Mims Manual
Books. Drugs in Pregnancy and Lactation: Briggs, Freeman and Yaffe, William
and Wilkins. ISBN 0-683-01060-3.
Drug referral – banks of computer information and hospital pharmacies
Website: www.motherisk.org and www.mayoclinic.com
- look in Health Living Centres.
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