Dear Nicky,
Our department writes and records most of the information straight into the
medical notes. The assessments and goals are written in the same entries as
the doctors. If more lengthy assessment and note-keeping are needed, an
additional sheet of information with clearly written headings is inserted.
The nurses notes, rehab professionals notes, surgery records, referrals,
biochemistry, test results are all kept in the same file. Depending on the
length of stay of the patient, this can be both convenient and cumbersome.
Long-staying patients usually have too much notes accumulated thus making
the whole file messy and difficult to sieve out information. However, this
is resolved with periodic archiving of past records that may not be so
relevant in the current medical management.
Multidisciplinary notekeeping is only useful if the professionals bother to
read each others notes. If not, it is simply a waste of time. I've
experienced many times when other professionals call/page me for information
that could be obtained from the notes I've written. It gets a bit annoying
repeating yourself.
Chee-Wee
> > Our hospital is about to begin mutidisciplinary notekeeping. If you do
> this
> > already please share your experiences?
> >
> > The doctors seem to think we can just write in the notes, but CSP
> > guidelines on notekeeping advise that we maintain an accurate physio
> record
> > of treatment.
> >
> > We are trying to design a sheet to add to the notes, but if anyone has
> > done this already please share.
> >
> > Thankyou
> >
> >
> > Nicky
> >
>
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