In Him I Trust
Do I have to copy everything? Not all, but some essentials. Let's see what they are ……Say you glanced at the doorway information saying " A 60 year old male Sang Lee comes to ER with loss of consciousness. BP 150/80 mm Hg , PR – 80/min, RR 14/min T 99.8 F ". Remember to remember the patients name before your hand goes to knock on the door. So it is a good idea to write the name down to use it then and also during the encounter. Age and sex ?– of course …..if you are thinking of premature menopause in a case of amenorrhea half way through history and happen to check her age on your blue sheet and find it to be 66 years, you probably will revise your diagnosis to a "definitely" menopause. Also say in the above case of Sang Lee, say the man gives a positive history of attacks of dizziness ….your mind goes " was he hypertensive ….what did I read outside? ..150 over…..over…???…" -so if the vitals are written on the blue sheet, you just have to glance down at your clip board! Also, when you come out after the encounter, if u had already written them before you entered the room, you just have to transfer it to the patient notes while typing! Bottom line……..please write down name, age, sex, vitals, chief complaints on your blue sheet before entering. Helps??? ……..I think so….