How To Write Clinical Notes

Improved Essays
I find myself frequently writing clinical notes for work. Clinical notes are; medical records where healthcare professionals record details to document a patient's status or achievements during the course of treatment. When writing these notes, I have to make sure my handwriting is legible and what I’m stating is comprehensible to minimize mistakes.
I specifically write these notes for dentists or whomever is treating the patient. These are necessary for giving the patient proper treatment. Whether it’s how many carpules of anesthetic the used from the previous visit, allergies, sensitivity, etc. These clinical notes are also used by receptionists and insurance companies, to charge patients what for their procedures.
The types of texts I

Related Documents

  • Improved Essays

    Handoff Report Sample

    • 671 Words
    • 3 Pages

    However, the study did average that the number of procedural patients is anywhere between 30 and 50 daily. 3. Research design: In the study a handoff group was formed and determined what information should be communicated and how the information should be available. The tool began as a paper form and after piloting the paper tool for 6 weeks, in formal verbal data was collected to measure compliance with and usability of the tool. The tool consisted of patient demographics, initial diagnoses, procedures performed, medical history, allergies, catheter access sites, vital signs, and cardiovascular device settings.…

    • 671 Words
    • 3 Pages
    Improved Essays
  • Decent Essays

    PCC can also improve clinical documentation by how they're charting templates that intuitively prompts staff to review and chart all pertinent clinical information (). PCC has a database that functionally allows users to enter information in one part of the chart and direct that information to other sections for auto-documentation as clinically indicated, such as the Resident Assessment Instrument/Minimum Data Set. This will ensure that every member of the healthcare team is being provided the most up-to-date clinical…

    • 79 Words
    • 1 Pages
    Decent Essays
  • Improved Essays

    Concerns or issues that the PA feels the primary physician should know are written down. This allows the two to work together in order to provide the most effective care for the patient. During the examination the PA may learn the patient’s height and weight as well as any other basic information needed. They will also talk to the patient to find out more detailed information about the problem the patient is having, this information is then put into a clinical SOAP note. The note has four sections including subjective, objective, assessment/problem list, and plan3.…

    • 1031 Words
    • 4 Pages
    Improved Essays
  • Decent Essays

    I also look for the patient’s lab and imaging results, and recent vital signs to obtain objective data. I will obtain the subjective data by asking the patient his/her chief complaint, symptoms, current health status, past medical health history, current medications, allergies, family and social history. Before I will enter the patient’s room, I ensure to wash my hands or use the hand sanitizer gel to prevent the spread of infection. I start my assessment my introducing myself to the patient. The room must be free of any distractions and the curtain should be completely closed for privacy.…

    • 622 Words
    • 3 Pages
    Decent Essays
  • Decent Essays

    Assignment #1 Stakeholder: VP of Nursing System: Clinical Documentation System Over the past decade there have been many advances in software that provide advantages for clinical documentation. Clinical documentation is at the core of every healthcare encounter and current legislation dictates that it must be accurate and complete. If clinical documentation does not adequately and precisely reflect the treatment and outcome of each encounter, the actual quality of care that was delivered could be seen as irrelevant. With changes to the way healthcare is funded, clinical documentation, or the resultant data and information extracted from that documentation, is how providers and organizations are being measured and adjudicated. (Jamal, 2014) Benefits There are many benefits to be gained from the implementation of a new clinical documentation system but essentially…

    • 495 Words
    • 2 Pages
    Decent Essays
  • Improved Essays

    The language with which the healthcare workers use in their notes is one that takes an individual to decipher. As an intern at the Emergency Department of the Johns Hopkins Hospital, I got to witness many patients coming in with diverse needs and in turn observed the method of notetaking nurses that I had the opportunity to shadow use in recording the complaints of the patients. When I shadowed a nurse in the Emergency Critical Care Unit, she displayed the electronic medical records on the computer screen after visiting a patient's room. I observed her as she added more comments on the progress of the patient. While she was typing I made an effort to decipher what she meant by terms like I&D by recalling all the medical terms and abbreviations…

    • 241 Words
    • 1 Pages
    Improved Essays
  • Improved Essays

    From charting and documenting procedures to helping patients with insurance paperwork. In the article, “What is Written Communication in Business?Definition, Types, & Exmaples” by Ashley D. Manker discusses the advatages and disadvantages of written communication. She says that one of the advantages is “Provides written proof in case of a dispute.” Every piece of paper in the medical field is a legal document and having a hard copy of a document will come in handy when verfying certain things in the workplace. A disadvantage that she mentions is “Lack of Secrecy.…

    • 777 Words
    • 4 Pages
    Improved Essays
  • Improved Essays

    Most hospitals use charts to record patients' information, so they will need to write legibly and not use abbreviations unless everyone would understand them. After charting is finishing they will most likely have to enter it into an online program. Some of those programs could include Microsoft Excel, medical software, and the hospital's electronic mail…

    • 1216 Words
    • 5 Pages
    Improved Essays
  • Great Essays

    One of those skills is one has to know how to write. Most practices do not write charts anymore but one must know how to due to the fact that computers do crash. Knowing how to type is a big skill one must obtain. This skill will be used every day when one charts for patients. Almost every patient will require one to make notes on their chart at some point in the treatment.…

    • 1324 Words
    • 6 Pages
    Great Essays
  • Improved Essays

    Case management consist of different disciplines in the care of a patient. I have interviewed a case management RN who works with the patient. I also interviewed another person only to have a different prospective of delivering care to a chronic pain patient during surgery. The other interviewee is an anesthesiologist that works at my ambulatory surgical center facility. Therefore, I have 2 people’s point of view of caring for a patient with chronic pain.…

    • 1031 Words
    • 5 Pages
    Improved Essays
  • Improved Essays

    Patient Assessment Paper

    • 1562 Words
    • 7 Pages

    Today I have the pleasure of working with a client named Mrs. Reyes, a 75-year-old female of Hispanic descent. She is a non-insulin diabetic, who lives alone, but has regular visits from her children and grandchildren. Mrs. Reyes has been admitted as a result of an acute change in mental status, and secondary with a diagnoses of a urinary tract infection and dehydration. Mrs. Reyes has a history of many falls at home previous to being admitted therefore she is a fall risk. I am nervous about how the day will go as this is the first time I will be working with Mrs. Reyes, and from report it appears that she did not have the most pleasant night.…

    • 1562 Words
    • 7 Pages
    Improved Essays
  • Improved Essays

    In the video, the mother of the patient was able to get the medication needed from the pharmacy shop immediately after the visit from their healthcare provider. to get the patient's medications available to the pharmacist so that it will be ready to be retrieved by the patient. Handwritten notes from doctors have the possibility of having illegible handwriting. This could lead to misunderstandings and lost information in deciphering for not only with the patients but other healthcare providers. Sometimes words are cut short or abbreviated on these notes increasing the chances errors.…

    • 578 Words
    • 3 Pages
    Improved Essays
  • Great Essays

    It also keeps a record of any problems and action that may need to be taken. Also that we need to record if there are any kind of factors that will affect the service user. This also has a purpose to make sure we are accurate in whatever we write down, and anything that happens should be noted down as soon as an even has happened. It needs to be dated, timed and signed. Provide clear evidence of the care planned, decisions made, care delivered and information shared.…

    • 1566 Words
    • 7 Pages
    Great Essays
  • Improved Essays

    This week’s bible passage made me reflect on my clinical rotation at the clinic while shadowing a nurse who was doing an anatomical procedure to an offender who accidentally fell and injured his head. Anatomical is the procedure that any nurse will do before they will assign any offender to segregated or isolated locked rooms or to any offender who needs to be assessed after an event that resulted in an injury. There was a bruising and a “bump” on the back side of the offenders head due to his bad fall. The swollen “bump” measured 3.4 cm. in width by 4cm in length.…

    • 702 Words
    • 3 Pages
    Improved Essays
  • Improved Essays

    There has been a history of poor communication in the medical field that has stemmed from physicians not being able to communicate well. Physicians are having issues trying to use medical terminology and also convey the meaning of the terminology to their patients. Some patients walk away from the doctor 's office feeling as though they still don 't understand what exactly is going on with them. Physicians do not realize that the medical terminology is creating a disconnect between their patients. Communication in the Health Care System is a skill that is necessary for Physicians; however, they lack the ability to listen, speak w/o using medical jargon, and write effectively.…

    • 814 Words
    • 4 Pages
    Improved Essays