how do you read medical notes?

[clc26]

i know this sounds a stupid question, but im a 4th year and i struggle with a pile of notes. the doctors seem to look at it for a few mins and know the Hx, diagnosis and what invest have been done. Are there any tips to get to grips with how to assimilate this info. In the medical notes section it seems to me to go on and on and on, do i start at the beggining which could be months ago and read every entry from the assessments and ward rounds?
any help will be mucho appreciated.

[Admin]

There should be a new complete clerking each time a patient is admitted. I would start at the initial clerking for the current admission and work through from there. Also look for the typed clinic notes relevant to the admission - i.e. if the admission is for surgery, look at the letters from the surgeon to the GP in the back.

[kate-l]

ITA about the most recent clerking, but the best trick is to look at the most recent clinic letter (usually consultant to GP, can be any, not just the most recent admit, go for the most recent letter) and to crib the problem list (often not just diagnoses but social issues, etc.) it usually has a drug list too. Once you start getting more experience of clinics with consultants/registrars you'll realise that this is how they do it too - rather than the inifinite memory some of them wish we thought they had!

[pipedreamer]

The most recent clerking is useful provided it's reasonably comprehensive and in legible handwriting (neither are guaranteed!) but can be hard to find if there's lots of handwritten notes and the patient has been in for a while.

I usually go straight to the correspondance section and read the most recent letters. As someone mentioned above, the letters usually have a list of recent problems, important medical conditions, social factors, drugs etc. A nice quick way to get a summary of the case (but obviously beware of things being missed off the list).

[Varied A]

It can be really tricky. One of teh wards I worked on has a system of sticky labels in the margin which denote what the entry is about - clerking, ward round, report on investigations, procedure note etc., which made it really easy to glance through and grab the info you need.

Letters to/from GPs can be useful for ascertaining long-term health status and background info, but generally less useful if you want to know the condition of the patient on the ward - for that, looking to the clerking done on admission then the ward round entries is probably the easiest way. Also, depending on how the nurses work where you are, there's often a daily "catch up" type summary in their notes somewhere.

[yazoo]

i know this sounds a stupid question, but im a 4th year and i struggle with a pile of notes. the doctors seem to look at it for a few mins and know the Hx, diagnosis and what invest have been done.

Tips as above. Also useful to note that the Drs may already know the patient, and may be looking at their own clinic letters, which speeds things up a lot for them. Also, in each hospital, there are always Drs reknowned for very thorough and comprehensive letters/clerkings. Sometimes you ignore the most recent letters (except for pertinent changes) in favour of these. hat takes knowledge that you will not have!

Everything makes it slow to begin with. Poor knowledge of terminology and abbreviations makes reading (guessing!) bad writing very hard.

It is a skill that takes practice - as of the rest of medicine.

One thing not mentioned so far - there is often a specific layout for notes that can vary from hosital to hospital. Results in one section, correspondence in another etc. Take the time to figure out how it's done where you work.