Your First Medical Clerking - Tips, Trips, and Trips for the New Foundation Doctor - Part 7
Summary
This medical teaching session will provide an overview of medical documentation and its implications on patient care. We will discuss how mistakes can have serious implications on patient safety and explore various processes to ensure these mistakes are avoided. We will also review differences between medical school processes and real world practice and propose ideas to improve medical documentation and reduce the risk of harm to patients. Participating in this session will help medical professionals stay up to date on the latest advancements in patient documentation and safety protocols.
Learning objectives
Learning Objectives:
- Understand the importance of accurately and thoroughly documenting medical information.
- Recognize examples of inadequate medical documentation processes and potential risks associated with them.
- Identify opportunities to improve documentation processes in order to reduce errors and enhance patient safety.
- Discuss the principles of proper clinical documentation for a medical professional.
- Implement strategies for accurate and successful clinical documentation.
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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.
back. So you guys to fix every time? Okay, so, yeah, like I said, many reasons. Why such important doctor? Actually, looking at some of this data that I've copied on the bottom Can you just want to talk? Let me know that you're seeing what I'm saying. We actually do a pretty good job of it. So this pain from Richard, that's our admittedly looking at American documentation. There's never just funny drug areas per medical parking. If you think about the number of medications come in, that's really high rate and actually quite dangerous practice. And then another paper here that it's an ambulatory markings on gets quite interested. They can actually that building bell it out last year, and they took medical Clarkin's thousands of them. I think if I remember, and on the patients, how many of these containers and even what you said on your medical history, nobody can see thanks Karen. One in five contained hours been off that one in 5. 40% were considered serious from a patient. So despite the fact that medical card thing and take shifts are really important, where patients undifferentiated this huge scope for medical era and harm to patients. We actually do a really bad job, which is good for people, like living lectures like me and collecting information is it means a lot of stuff for improvement. What you guys gonna be absolutely fantastic. It it and for a better than I am. So what? There's a cracking pro forma look like, and we'll go for him to speak about it. And if anyone has any ideas about how we can make it better, or how we can do things better than let me look around, But if you look at this for out and I'll read it in a minute, it's actually very similar to the carpet you do in medical school. But with some final difference is the difference is, I believe are important here because no, only we doing what we do in medical school. We're trying to work out because of the patient's presentation and we're getting to act. But also we're providing really important information for people that come after us, and that's not just in terms of the presenting complaint and how we manage the patient. I think that's where the subtle differences I think that's where there's a great school for improvement, as you saw from where weapon That Aquarius happened last time. So I'm not gonna talk to much about presenting complaint history presenting complaint because you