I’ve been running my own community eye care practice for two years and some of my early patients are coming back for their next eye examination. I’m surprised by the poor quality of some of my record-keeping. I’ve written down patient symptoms and signs and done any investigation of them or noted any management of them. How can I get better at making notes that show I have investigated and managed patient symptoms and signs?
I find this a struggle as well. It is good that you have taken the time to review your records and have noticed that some of them could be improved.
I’ve started to look at my clinical records as a story told by each patient. There is a beginning a middle and an end and like all good stories these sections need to make sense and they need to be connected.
The history and symptoms section is the introduction to the story and set the scene. Any symptoms or signs the patient has at this stage of the story become the main actors. The main actors are then expanded upon using further questioning clinical tests. Most clinical tests should be connected to the symptoms and signs. Some clinical tests such as measurement of visual acuity and intraocular pressure testing may not be connected to the main actors. But if the main actor is occasional diplopia, then a clinical test that should be connected to this is oculomotility testing. Then the end of the story should be the management of the main actors (symptoms and signs). Continuing with the diplopia theme, if oculomotility shows good eye movement in all positions of gaze then prism or eye exercises may help. If there is an underacting muscle then referral to an ophthalmologist would be helpful.
Another main actor, clinical test, and end-of-story connections would be a painless red eye, slit lamp examination, monitor and review.
There are many possible stories.
When you have finished the examination, identify the main actors, and check that each one is connected to a clinical test and that it gets a mention at the end of the story.