Medical charting: Advice for the incoming intern

Medical charting: Advice for the incoming intern

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The goal of charting is to convey information, and have an accurate record of events. Here are a few tips for any incoming medical intern.
13 Sep 2016 - General
Mark Edmon Tan That'a a good way of organizing the SOAP plan. From our hospital standards, its recommended that we put measurable goals in the progress notes. For example: Relieve pain to a visual pain scale of 3/10 or Early mobilization with a target of standing up exercises on day 2 post-operative. If these goals are not met, then it is an indication that either there's something lacking in the present ...
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Marinelle Castro "Always practice honesty." That is very important when writing something down in the chart. It is a legal document and should not be tampered with. For the plan part of SOAP progress notes, our hospital has recommended to divide this part into three segments: diagnostics, therapeutics, and education. For example, reported acute back pain of a female may have the following plans: diagnos...
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My advice to incoming medical interns is to first, devise a system in doing a chart review. You should familiarize yourself with the parts of the chart so that it will not take so much time to go through details of the chart whenever you are going to make your notes. Second, always practice honesty in professionalism in everything that you do. A medical chart is a legal document so you should always be careful of what you write. Also, avoid using medical jargons, unaccepted abbreviations in the ...
 (Total 136 words)