Mastering Hospital Progress Notes: Enhancing Efficiency with AI Medical Scribes
Effective clinical documentation is crucial for ensuring accurate patient care and communication among healthcare providers. Hospital progress notes serve as a vital component in the patient charting process, providing a detailed account of the patient's current status and the treatment plan. Here, we present a comprehensive guide on how to correctly write and format a hospital progress note using a structured template, focusing on general practitioners.
Let's break down the template:
ID:
Example: 67, Female
Level of Care B (discussed)
Start with the patient's basic identification details and the level of care they require. This sets the context for the rest of the note.
Reason for Admission:
Example: Acute exacerbation of chronic obstructive pulmonary disease (COPD)
Clearly state the primary reason for the patient's admission. This helps in focusing the assessment and treatment plans.
Past Medical History:
Example: Hypertension, Type 2 Diabetes, Osteoarthritis
Include a brief overview of relevant past medical conditions that may impact the current treatment plan.
Allergies:
Example: Penicillin
Document any known allergies to avoid adverse reactions to medications.
Today:
Example: Increased shortness of breath, productive cough
Provide a brief summary of the patient's current symptoms and condition.
On Examination (OE):
Vital signs: BP 140/85, HR 88, Temp 37.2°C, RR 22, SpO2 92% on room air
Good General State, no distress, no work for breathing
Heart: normal S1, normal S2 with no murmurs
No LL Edema
Lungs: Normal Vesicular breathing, No crackles, No wheezing
Abdomen: Soft, no tenderness, no Rigidity, no Rebound, negative Mcburney sign
The examination section provides a detailed account of the patient's vital signs and physical examination findings, crucial for forming an assessment.
Investigations:
Labs: CBC: WBC 12,000/mm³, Hb 13.5 g/dL, Platelets 250,000/mm³
Imaging: Chest X-ray: Hyperinflation, no acute infiltrates
Record any laboratory tests or imaging studies that have been performed, along with their results.
Treatment Plan:
COPD exacerbation
Impression: COPD exacerbation
Treatment planned: Nebulised bronchodilators, oral corticosteroids
Relevant referrals: Pulmonology
Hypertension
Treatment planned: Continue current antihypertensive regimen
Diabetes management
Treatment planned: Adjust insulin dosage as per sliding scale
Discharge Planning & Other:
Prophylactic anti-coagulation: Lovenox
Foley catheter: No
GFR/Kidney function: GFR 65 mL/min/1.73m²
Outline the treatment plan, including medications, referrals, and any discharge planning considerations. This ensures a structured approach to patient management.
While traditional methods of documenting clinical notes are effective, they can be time-consuming and prone to human error. This is where AI medical scribes, like the Notis AI Medical Scribe, come into play.
Time Efficiency: Notis significantly reduces documentation time, allowing general practitioners to reclaim up to 2 hours per day. This time-saving is achieved through advanced voice-to-text technology that transcribes clinical encounters into structured SOAP notes.
Ease of Use: With integration into WhatsApp, Notis eliminates the need for additional software, providing a seamless and familiar interface for healthcare providers.
Accuracy and Multilingual Support: Notis boasts a 99% transcription accuracy rate and supports 56 languages, ensuring accurate and comprehensive medical notes across diverse patient populations.
Comprehensive Features: From smart search and retrieval of patient information to document and image analysis, Notis offers a robust solution for efficient patient charting.
By adopting AI-powered virtual scribes, healthcare providers can streamline patient documentation, enhance productivity, and focus more on delivering quality patient care. In the evolving landscape of healthcare, leveraging technology like Notis AI Medical Scribe is a step forward in improving clinical documentation and patient outcomes.
Example Note
