where did june go?
July 13, 2008
failing to blog in over a month is not evidence of an event-free six weeks. there is a lot to report, many interesting patient-stories to tell. i’ll try to hit the highlights over a few separate posts…
right now i’m scanning over past patient lists and chart notes to jog my memory of who i’ve seen over the past few weeks.
a “patient list” is just as it sounds — a list of patients that my preceptor (MP) is following. MP and i use the list to plan out our day and to prioritize what patients we’ll see based on any new consultations receieved (from the docs) or based on each patient’s risk level (i.e. their level of nutritional need/acute illness).
a “chart note” is a written record of the care provided to a patient. please forgive me if this is tedious. at our hospital, all of the charting is done online, which is extremely convenient. laptops are scattered throughout the building, allowing us to look up past notes, lab values, medication lists, past medical histories from anywhere, anytime. computerized charting also allows us to write our assessments in a clearer way (read: full sentences with no need to decipher horrible handwriting). the ability to cut and paste information is also priceless — we don’t have to spend time rewriting past medical histories or quotes from other practitioners — we can simply ctrl+v it into our notes. awesome.
most hospitals are still charting by hand, which tends to be messy and time consuming. i’ve absolutely learned that if clinical dietetics is in my future, e-charting may be a necessity.
