Question

What is the Rules for writing patient notes in the medical interview guide

Answer 1

Rules of writing patient notes in medical interview:

There are some rules while noting down patient interview so that it will be helpful to anyone who is concerned with the patient and all medical and paramedical staff.

They are as follows,

1. Mention the patient details like name, age, weight,address, date etc.

2. Mention the complains of patient. They should be mentioned in chronological order as seen by patient. They should be in patient's language.

3. Take the detailed history of patient and use medical terms for complains.

4. Write down clinical examination performed as general examination and systemic examination.

5. Mention details of investigations and their results along with date on which it was performed.

6. Mention provisional diagnosis from above information and discuss it with patient or relatives.

7. Mention line of treatment in notes and discuss it with patient. Any changes in treatment should be justified.

8. We have to be organised while writing notes as it can be used as information source by various medical professionals. Be brief and to the point while writing notes. Use standard abbreviations where necessary. Handwriting should be good.

These are some rules while writing notes in medical interview.