Important Components in a Case Note • • Date and time• • Make sure each continuation sheet has patient’s name & IC / RN Reminders • Case notes must be written , and precisely • Case note is a legal documentation and it is also a form of communication among colleagues / with other teams […]
I would divide investigations into 3 parts (i) Bedside test(ii) Blood test(iii) Other lab tests(iv) Imaging Bedside test • ECG• Dxt Point of care test (POCT) What is POCT?Simple medical tests that can be performed at the bedside without sending the specimen to the laboratory / sending patient to Radiology department Examples• Pulse oximetry• ECG• […]
STEP 1: Comorbidities • Ask about underlying medical illness(es) and the follow up. Which clinic, which hospital, government or private? • Previous history of admission(s) and why• Any recent admission? • List down all current medications correctly • How is the patient before this current illness sets in?• Social history • Is patient still working? […]
Original Logbook (i) Major Postings • Medical• O&G• Orthopaedics• Paediatrics• Surgical (ii) Elective Postings • Anaesthesiology• Primary Care• Psychiatry• Emergency Medicine Pandemic Logbook (i) Major Postings • Medical• O&G• Orthopaedics• Paediatrics• Surgical (ii) Elective Postings • Anaesthesiology• Primary Care• Psychiatry• Emergency Medicine Source: https://www.moh.gov.my/index.php/pages/view/2927?mid=1329