Respuesta :
They include a summary of the key points discussed and record your conversation with your doctor, nurse, or other healthcare providers. The notes connect the other parts of your medical record and tell the story of your medical care.
What is a patient note?
- A patient note is the primary communication tool to other clinicians treating the patient and a statement of the quality of care. Although EHRs are designed to help you write patient notes, the note ultimately originates with you, the doctor, or the caregiver, not with the EHR.
- Your EHR might improve the quality of your note, but it can also make them more challenging to read. Regardless of your EHR, you can create a solid and succinct note by adhering to a few documentation best practices.
- Make sure you adhere to the two accepted note-taking formats, SOAP (subjective, objective, assessment, and plan) or APSO (assessment, plan, subjective, objective). Four sections (SOAP or APSO) should be included in a patient note, and there are two proposed approaches to writing an efficient and informative note.
- The first step is to thoroughly evaluate the patient's medical history, including prior notes, to understand their condition.
- The second step is to confirm that the patient has followed the previous treatment plan, which may have included taking prescribed drugs, completing diagnostic testing, attending main and referral appointments, following a diet, etc.
To learn more about patient notes, refer to:
https://brainly.com/question/15243861
#SPJ9
