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FACP. Colegio de médicos de Tarragona Nº 4305520 / fgcapriles@gmail.com




Tuesday, June 2, 2020

Charting in the ED

CanadiEM - By Stella Tung - June 2, 2020
"The Bottom Line:
Tedious as it may be, documentation is a fundamental skill that you will need throughout your career in medicine. After all, if you didn’t write it, it didn’t happen, and it’s your responsibility to capture what happened throughout the patient encounter.
For clinical clerks and even junior residents, using the process of documentation to organize your thoughts is helpful not only for your own understanding, but also for better communication with other providers (e.g. consultants). Think of it as a piece of writing that convinces the reader which diagnosis is most likely using the information you have collected, and use the process to also brainstorm which diagnoses you wouldn’t want to miss. While sometimes it seems easier to write down everything you can think of, I challenge you to continue the pursuit of writing succinct notes throughout your education, which will ultimately make this administrative task an easier one and help you to better enjoy your clinical job as a whole."