Transcript Medical record: shariing dilemmas and cases

Paula Wright
Northern deanery lead for Sessional GPs
Why important
For appraisal and revalidation- record
keeping is one of the 12 domains which
we need to demonstrate good practice
in
 Relevant to negligence
 Continuity etc
 For audit, chronic disease management
and many other reasons
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Structure- SOAP
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S- Subjective what the patient says
Objective- examination and test results
Assessment- your conclusions and Diff D
Plan: meds, consent, referrals, options,
safety net, advice, joint decisions
Information: patient wishes, disc of options,
info given to patient, questions answered
Follow up: arrangements and safety net
Common problems
Neg findings
 Disc about risks and benefits
 Drug allergies and Adrs
 Illegible
 Not reading notes before seeing patient
 Making derogatory comments
 Altering notes after event
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Key points
Clear
 Objective
 Contemporaneous
 Attributable
 Original (corrections: when why what
changed)
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When to write more detail
Patients who appear :
 Unhappy with the consultation or critical
of their care
 Sig unwell (child)
Where there is:
 Diagn uncertainty; complex hx,
disagreement about management,
repeated attendance for same problems,
unexpected progress in condotion
Shared tips
To capture safety netting quickly:
 State “review if Red flags as per NICE”
 Use a macro, autoconsultation
(systemone) or “shortkeys light”
 State advice as per advice sheet by
XXX
 PILS given
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