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| Author | Subject: case records |
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 nerius
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case records
Feb 12, 2005 21:34:03 Just a quick question.
Under H&S, if the patient is fine, should I just write GOOD instead of writing no diabetes, no HBP, no allergies etc The latter looks real untidy so was just wondering.
Same goes for POH and NONE instead of no cataracts, no glaucoma, no squint etc you get the point |
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palfi
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RE: case records
Feb 14, 2005 11:03:21 many people put a little circle meaning zero insted of no hbp etc. Mind you - I think it is worth itemizing things which the px would be at risk with. Ie if a child it is pointless putting POH glaucoma o, while a history of squint would be far more interesting. It is a point that most px only remember 60% of hteir history, so your questions should dig for the other 40%. I don't like POH - none as it would imply to me that nothing has ever happened to them. Try to use the px own words and always ask about floaters and pains - even if the answer is 'no' (and always record it). Then you are covered against GOC claims of missing a det ret. |