Your First Medical Clerking - Tips, Trips, and Trips for the New Foundation Doctor - Part 6
Summary
This on-demand teaching session is designed to help medical professionals better understand the importance of thorough documentation in the healthcare setting. It emphasizes how documentation is a legal document and provides the necessary details and justification for patient care decisions. It also exlains why it takes so long to do a detailed patient assessment (such as car king) and how it serves as vital reference material for future care. Attendees will gain valuable insight into how to ensure they are properly documenting patient histories and treatments to ensure safe, high-quality care.
Learning objectives
Learning Objectives:
- Understand the importance of taking adequate time to complete a thorough medical history.
- Recognize the implications of unsafe treatment or inappropriate treatment on a potentially critically ill or undifferentiated patient.
- Learn how to document a medical history in a way that is legally sound and will provide a useful summary of events.
- Become familiar with the reference document generated by a junior doctor following a medical encounter.
- Comprehend the importance of documenting past medical history and other important details in order to guide future decisions.
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Computer generated transcript
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
sorry, quick fix every time she did there with me. So I speaking this. There's a load of things that we get up to some of these activities. They're actually quite high risk in what's important that we take our time on. You can see now why it takes two hours to do a full a full car king, including all of these jobs. And the point is that we don't do it fast because actually a any will be seeing a patient quickly and getting through huge numbers and initiating treatment. But it's really important that we do a thorough job because actually, this is a lot quite high risk stuff. I mean, if you're taking a full medical history and you don't document appropriately, that's going to influence a large amount of decision making over the next couple of days. If we initiate some unsafe treatment or potentially treatment isn't indicated, that's gonna have some huge implications on an undifferentiated, potentially a Z unwell. Is there going to be a lot of the time patients in a similar things, like VT prophylaxis that might not get picked up for a couple of days after you see a patient the outpatient meds. So this huge amount of really high every stuff that we need to be safe to take a lot of time over, um reminds it's such an important document. Well, first off, obviously, it's a legal document as our medical documents and you're justifying the actions. Your undertaking in some settings particular is you get more senior when you see a patient on the medical take. You may actually initiate treatment before you've documented anything because they're quite sickening, differentiated patients. But it's really important that you document your history or your blood results and all of your findings to justify what you're doing with the patient, because essentially, it's a legal document. It also provides a really useful summary of events, not just the or post a consultant he verbally and over. But I dark you that the medical crackin on the one done by a junior doctor, not the post State park in is probably the most reference document for our Patients Day on the war. You might like a couple of days back in the in the medical world around notes, but frequently you refer to the refer to the initial Clark It so it's really important we get it right. And that's not just for the presenting complaint in the history percent complaint, but also the really important details that we can speak about later. Um, your supervisory if rinse for future decisions. Say, for example, if a patient, if you document in your past medical history of patient, is a nice a patient on has an IV or a COPD patient.