Question

Rules for writing patient notes in the medical interview guide

Answer 1

Patient notes should include identifying data, past history, review of systems, family history, social history, vital signs, medications, assessments, diagnoses, etc. To write these details the following rules should be followed:

1. A consistent format should be used to write patient notes.

Each record should be begun with patient identification information. It should also include the interviewer’s full name and the date/time of the interview.

2. Patient notes should be written in a timely manner.

Notes should be within 24 hours of care giving and supervision of the patient. Observations should be written along with the necessary care provided when the memory is fresh so that only 100% true information is given.

3. Standard medical abbreviations familiar to other healthcare professionals should be used to write patient notes.

4. The patient notes should be objective based on what is seen and heard. Avoid subjective comments or interpretation of the patient's condition.

5. All patient communication should be noted down.

6. Any trivial information should be ignored in the notes.

7. It should be kept simple and clear, and should be written in legible handwriting when the notes are handwritten.