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Case Notes |
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1. Planning and continuity of care. 2. Communication between medical staff. 3. Evidence of recovery and management. 4. Evaluation of clinical care. 5. Research data. 6. Protect the legal interest of the patient, staff and hospital.
Always date and sign each entry clearly, and ensure that the patient’s name appears at the top of the page. Clerk the patient and record any findings in the notes along with any differential diagnoses. The results of blood investigations should be entered with the date of sample in red ink.
Operation notes 1. Date, summary of operation. 2. Name of surgeon/ assistant and anaesthetist. 3. Description of incision. 4. Findings—either normal or abnormal. 5. Results of intra-operative investigation eg frozen section. 6. Record the procedure preformed and any difficulties encountered. 7. Note placement of drains. 8. Method of wound closure and suture used. 9. A diagram of the operative procedure is often useful. 10. Post operative instructions.
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It is your responsibility to maintain clinical records daily, never assume that someone else will oblige. Entries should always be neat and concise without any obscure abbreviations and always professional—remember patients are now able to gain access to their written records. Case notes provide: |
