Template & Tips: Writing a Medical Chart Entry

Author: Dr Alex Matus

The following is an example of a general medical note 

Overview: Patient X is a X age, X sex admitted on X date for X presenting complaint on the background of X (gives context for perhaps what/why the diagnosis is/could be)

Issues:

1. 1. Pulmonary oedema
      • • Likely secondary to left ventricular failure
        • Cardio consult X date advised Y
        • Echo X date identified Y
        • Managed with furosemide, fluid restriction
        • Symptomatically improved by X date
   2. Next problem…

Background:

• • PMHx
    • HTN
    • T2DM
    • AF
  • Medications
    • Amlodipine 5mg daily
    • Metformin 1g daily
    • Apixaban 5mg BD
  • SHx
    • Lives at home with X
    • Former accountant
    • Nil services, independent ADL
    • Nil mobility aids
    • Nil EtOH, nil smoking

Progress:

• How the patient is feeling/progressing +/- history
• Summary of interaction with patient and things discussed

On Examination:

• • General inspection
  • Assess cognition/mental impairment/GCS as relevant
  • Vitals
  • Clinical signs by relevant body system

Investigations (include dates)

• • Bloods
  • Micro
  • Imaging

Plan:

• 1. Daily input/output measurements and daily weights please
  2. IV furosemide 40mg BD
  3. OP echocardiogram FU
  4. Continue AH for disposition planning

Advantages of using the above structure:

1. Structure: enables notes to be easily read, and can be directly used for discharge summaries
2. Including actual dates (not yesterday, today, tomorrow): explains events chronologically, reduces the risk of error (esp. when notes are further copied or pasted)
3. Quick reference: easy reference for all members of the team (esp. in emergencies) without need to search for information in various places.