clinical notes

RE: clinical notes

Anthony Dennison — Mon, 03 Jul 2017 12:22:35 GMT

Depending on the situation, I may write very little, or a lot.

Routine booster, nothing found: 'OR no probs, DUDE normal, GHC aok. Teeth good.' If it's a rabbit I'll mention about diet, teeth, gut sounds.

If I have a difficult client I go overboard and put everything in, what the client said etc. I have the benefit of that a little when I'm at a quieter branch I have time to do this.

RE: clinical notes

Neil Wheadon — Fri, 30 Jun 2017 09:24:45 GMT

[quote user="mariette asselbergs"]

Yes Neil, not long ago you sent a patient from one of our user practices to our OOH practice and the notes accompanying the animal were as above and the best and most useful I ever received. They were relatively short (no waffling), but very complete and logical and showed the thinking behind the treatment plan the animal came with so for us it was also very clear what you wanted us to do.

You could lecture on this topic!

Mariette

[/quote]

Shucks - Thanks

'Always think of the next man' Jack Glanville - 70 year old farm workers sagely advise to a 14 year old stacking hay bales at Hardicott Farm, Devon

RE: clinical notes

Evelyn Barbour-Hill — Thu, 29 Jun 2017 17:58:09 GMT

[quote user="Anthony Todd"] to cover your ass in the unlikely event that something will emerge?[/quote]

Anyone remember those stupid things where you pressed the donkey's ears and a cigarette emerged from its rectum?

Oh how we laughed.

RE: clinical notes

Julie Innes — Thu, 29 Jun 2017 16:32:52 GMT

I think it's trying to get a balance. I get what people mean about less being more, but sometimes vets leave out something that was important to the client- eg "Can you have another look at that lump- X checked it last time and said it was a (can't remember) and just to keep an eye on it. I think it might have grown- has it?" and I have to admit that there is no mention of this in the notes (probably brought up as a "while I'm here..." while in for something else) So I do try to add little things that might crop up again- client reports scratching ears- nothing to see, adv monitor (while it's getting bloods done for a potential splenic mass....)

RE: clinical notes

Anthony Todd — Wed, 28 Jun 2017 11:41:36 GMT

Yes, sorry, times and emphasis have changed.......

RE: clinical notes

Clive Ansell — Wed, 28 Jun 2017 10:47:53 GMT

[quote user="Anthony Todd"]So are they "clinical notes" or a narrative to cover your ass in the unlikely event that something will emerge?[/quote]

My donkey is just fine and couldn't care less, but I agree a certain element of clinical notes is about making sure ones arse is well and truly covered in this over litigious age.

RE: clinical notes

Robin Grimmer — Wed, 28 Jun 2017 10:39:19 GMT

[quote user="Anthony Todd"]

[quote user="Wren"]I disagree, it's totally valid[/quote]

So are they "clinical notes" or a narrative to cover your ass in the unlikely event that something will emerge?

[/quote]

Sadly these days I think it's both. Take my example earlier where I recorded in the notes a phone call with a particularly difficult client - proved invaluable in the end in disproving a complaint to the practice (in which I was only marginally involved)

RE: clinical notes

Anthony Todd — Wed, 28 Jun 2017 10:33:56 GMT

[quote user="Wren"]I disagree, it's totally valid[/quote]

So are they "clinical notes" or a narrative to cover your ass in the unlikely event that something will emerge?

No abnormality detected means that you have examined the animal and detected no abnormality.

Notes aren't defensive, as they are clinical notes and not a Veterinary Defense Document?

I suppose you could just write "conjunctivitis etc." as it should be assumed to would check the animal as routine so even "otherwise NAD or plain NAD is unnecessary?

RE: clinical notes

Wren — Wed, 28 Jun 2017 10:00:28 GMT

[quote user="Anthony Todd"]

[quote user="Iain Richards"]"otherwise NAD"[/quote]

Surely "otherwise" is unnecessary; it's either NAD or not....

..."sudden cardiac arrest, otherwise NAD......"

[/quote]

I disagree, it's totally valid. 'Bilateral conjunctivitis, otherwise NAD'. The second part of that sentence is to let anyone following know that I have asked the client re general health (appetite, coughing/sneezing etc.) and performed a cursory clinical exam and am satisfied that the presenting problem is solely confined to the eyes. If I'd just written 'Bilateral conjunctivitis' then my colleagues would not be able to presume that I'd done any of that.

RE: clinical notes

Anthony Todd — Wed, 28 Jun 2017 09:47:30 GMT

[quote user="Iain Richards"]"otherwise NAD"[/quote]

Surely "otherwise" is unnecessary; it's either NAD or not....

..."sudden cardiac arrest, otherwise NAD......"

RE: clinical notes

Iain Richards — Wed, 28 Jun 2017 09:08:56 GMT

While David's main thrust of, "less is more" is reasonable, it's not that helpful for new grads struggling between verbosity and clarity. I'd like to see a reference for the "95% of info is bunk" concept and while writing after the consult is fine, it must be immediate so the note is contemporaneous. I've done a bit of digging and found these sources:

Dutch 1994 study (small number of patients) on comparing what happened in the consult to what was recorded - only 32% of actions that were discussed were recorded. The figure was higher for medication, or lab work, but still only 68%

A wider review https://doi.org/10.1136/jamia.2010.007237 Included this, "Among existing studies, investigators have demonstrated that when compared to highly structured diagnostic or impressions data, clinical notes containing naturalistic prose have been more accurate,33 more reliable for identifying patients with given diseases,34 and more understandable to healthcare providers reviewing patient records.35,36 In addition, numerous structured documentation systems include components that generate natural prose notes to increase their acceptance,35,37–39 which implies that natural-language text has value to clinical users."

So, write what you like, remembering that someone will read it, possibly yourself! Wren has mentioned the SOAP approach which isn't a bad aid to have in your mind, so your notes have structure.

RE: clinical notes

Wren — Wed, 28 Jun 2017 08:50:35 GMT

We were taught SOAP at university (Subjective, Objective, Assessment, Plan), which although I don't consciously use, I have looked at some recent notes I have written and they follow this form. I have a slightly different set of circumstances to most of you in that my work is ambulatory, and the computer is in the practice, so the notes I write are done either at the end of the day (or in a busy period) a day or two later. You can tell when I am either particularly unsure of the likely diagnosis, or get a bad feeling from a client as I write about twice as much as usual!

RE: clinical notes

mariette asselbergs — Tue, 27 Jun 2017 22:48:26 GMT

You could lecture on this topic!

Mariette

RE: clinical notes

David Mills — Tue, 27 Jun 2017 21:48:15 GMT

[quote user="Anthony Todd"]Don't know who or where this came from but [not to establish a pattern!][/quote]

Very well established in human medicine. Fair few papers around "illness scripts" and what constitutes an expert. Or see my presentation at EBVM conference last year in Edinburgh....

RE: clinical notes

Anthony Todd — Tue, 27 Jun 2017 20:54:54 GMT

[quote user="David Mills"]Experts dismiss upto 95% of the information imparted during a consultation.[/quote]

Don't know who or where this came from but [not to establish a pattern!] I gave the post 5 stars.

I had the impression that the more notes that were written the less diagnostic or therapeutic the result.

PS: just remembered my NYD = Not Yet Diagnosed, which was often revealing to others following on.

RE: clinical notes

David Mills — Tue, 27 Jun 2017 19:19:37 GMT

Touch typers are the scourge of the profession as (even if they don't think they do) they almost always write too much because they can do so quickly. What they don't realise is that it actually detracts from the entry because the important stuff gets lost in the midst of waffle.

Some rules:

1. No complete sentences

2. Hx/ex/ddx/pl

3. Write notes after the consult, not during. That will cut out the extraneous information that you didn't psychologically require. Experts dismiss upto 95% of the information imparted during a consultation.

4. Brevity is levity and colleague sanity

Only on occasions (e.g. where there has been a screaming match) will any more be needed or if you get a red light from a client.

I like the PMSs that limit the amount you can write.

RE: clinical notes

ChrisBVSc — Tue, 27 Jun 2017 17:45:53 GMT

I'd also highly recommend learning to touch-type, sign up for an evening course or something if you have to & keep practicing. Makes life so much easier!

I try to write concise yet thorough notes, i.e. including anything that may be remotely important in concise language, but trying to stay waffle-free (notes full of dense waffle are a nightmare to read - but equally I can't stand bare minimal notes that don't tell you anything!) Generally divided into history/exam/diagnosis/treatment/plan.

Most notes end up fairly brief with common abbreviations used, but if I have a complicated case (or anything where I feel I need to cover my back) I will sometimes write fairly long-winded notes. This is where touch-typing is great, as I can write a whole page of text within a couple of minutes if necessary, therefore having minimal impact on the waiting clients!

RE: clinical notes

Martin Atkinson — Tue, 27 Jun 2017 17:10:34 GMT

[quote user="Clive Ansell"]

[quote user="Martin Atkinson"][quote user="Clive Ansell"] I have had at least one case where a practice owner has altered my clinical notes following a disgruntled client complaint.[/quote]Wasn't me was it?! [/quote]

No. The practice owner was more interested in placating and pacifying an awkward client, rather than supporting a professional colleague when up against a vociferous complaint.

[/quote]I know Clive, I've never changed anyone's notes other than my own because of innocent mistakes as previously listed. I can't understand why anyone would want to put up with such a client and would rather see the back of them than wrongly implicate a colleague however terrible he/she was provided it wasn't a real piece of negligence.

RE: clinical notes

Clive Ansell — Tue, 27 Jun 2017 14:45:10 GMT

No.

It was a case of a kitten with severe conjunctivitis that went belly up and the eye being eventually lost, mainly as a result of the owner declining investigation or referral, and repeated failing to keep check appointments.

The practice owner was more interested in placating and pacifying an awkward client, rather than supporting a professional colleague when up against a vociferous complaint. He had deleted my notes which stated "recheck t/m, and referral inb". Nothing every came of it though.

RE: clinical notes

Neil Wheadon — Tue, 27 Jun 2017 13:16:40 GMT

[quote user="Martin Atkinson"]No seriously the system should not allow thi[/quote]

With Rx, you could do, till last year. It's changed now, so each entry is logged with the time, (if done the next day?)

Neil

RE: clinical notes

Martin Atkinson — Tue, 27 Jun 2017 13:03:53 GMT

[quote user="Clive Ansell"] I have had at least one case where a practice owner has altered my clinical notes following a disgruntled client complaint.[/quote]Wasn't me was it?! No seriously the system should not allow this: a) it should be obvious additional notes were added at a different time/day and b) the original should be undelatable. With our system, notes can be removed (useful when they're duplicated or there is a gross typo) but are stored in a separate file from where they cannot be permanently deleted. If the proverbial then hit the fan it is possible be able to recall these either as self-defence or a wrongly accused employee/disgruntled client/RCVS whatever could subpoena them.

RE: clinical notes

Neil Wheadon — Tue, 27 Jun 2017 12:22:51 GMT

Another locums notes

Taken in random from a busy morning, for a 15 year old cat brought in

History-
Concern is weight loss
Was on senior food
Eating and drinking, always hungry
Vomits this morning, before then unsure

Examination-
Teeth aren't great- lots of tarter
HR 192, slightly muddy colour, CRT 1 sec
Abdomen clear, the kidneys are slightly small
I can't feel a thyroid

Diagnosis-
Multifactorial

Plan-
1) Re-assured that nothing dramatic externally
2) Blood sample STARVED tomorrow
3) With the blood sample can assess Thyroid function and other organs. Can also look at renal values for ARTHRITIS, as exhibiting signs of this. Can't jump to high places, lies with limbs extended. Therefore Metacam long term is indicated

Neil Wheadon MRCVS

Neil (I always right my name on clinical notes)

RE: clinical notes

Rob Davis — Tue, 27 Jun 2017 12:12:24 GMT

[quote user="Anthony Todd"]

Not nearly as much as irrelevant or insulting notes would p**s the practice owner off if the pet owner made a claim or engages the RCVS....!!

We had "owner is a hysterical idiot" or similar when a C/S died..... The PM showed massive S/C bruising down one side of the body so sounded like a car accident, but those sort of notes wouldn't have helped.....

and the owner had already demanded the notes......

We had a number of locums who delighted in writing that previous treatment was wrong [in some or all ways] as well!!!

And the next vet has to face this on the next visit, if there is one.....

[/quote]

I would hope that Clive's notes do not fall into any of the above categories....

RE: clinical notes

Anthony Todd — Tue, 27 Jun 2017 10:31:30 GMT

[quote user="Rob Davis"]Now that would seriously p**s me off, I hope you've never worked there again![/quote]

Not nearly as much as irrelevant or insulting notes would p**s the practice owner off if the pet owner made a claim or engages the RCVS....!!

and the owner had already demanded the notes......

We had a number of locums who delighted in writing that previous treatment was wrong [in some or all ways] as well!!!

And the next vet has to face this on the next visit, if there is one.....

RE: clinical notes

Rob Davis — Tue, 27 Jun 2017 08:46:36 GMT

[quote user="Clive Ansell"]

I have had at least one case where a practice owner has altered my clinical notes following a disgruntled client complaint.

[/quote]

Now that would seriously p**s me off, I hope you've never worked there again!