Key Feature Specific Field Note
Assessing Competence in family medicine

Search results for: Communication Skills with Colleagues (includes key features for Charting skills)
Theme: Language Skills - Charting Skills
Assessment should concentrate mainly on the charting of individual encounters. Overall organization and structure of the ongoing clinical record are important, but these are often predetermined and outside the control of the individual—they can be assessed, but in a different context. Note that these charting skills are formatted as a set of key features.

Select up to  key features to include in one field note.

1a) A clinical note must be legible.

1b) A clinical note must avoid using acronyms or abbreviations that may be misunderstood or confusing (e.g., "U" for "units").

1c) A clinical note must be organized so as to facilitate reading and understanding.

1d) A clinical note must follow an agreed-upon structure within a practice setting.

2. Charting must be done in a timely fashion, so as to minimize inaccuracies and lost information, and to ensure that the information is available for others involved in care. It should usually be done immediately after the encounter; if delayed, no

3. Corrections or changes to the note must be clearly visible as such, and dated if not made at the time of the original entry.

4. Should not write anything in the chart that you would not want the patient to read (e.g., disparaging remarks)

5. Must not falsify data (e.g., don’t include data in the note that has not been gathered)

6a) The clinical note must reflect all the phases of the clinical encounter that are relevant to the presenting situation.

6b) The clinical note must show an obvious and logical link between the data recorded and the conclusions and plan.

6c) The clinical note must include the relevant negative findings, as well as the relevant positive findings.

6d) The clinical note must avoid inappropriate verbatim reporting of the encounter (it should synthesize the data gathered).

7. As part of ongoing care, acknowledge additional received data (e.g., test results, consultation reports) and document follow-up action when appropriate.

8. As new information is gathered during an encounter, maintain the chart according to the expectations of the work milieu (e.g., flow sheets, summary page).

9. Structure and use the clinical record as a tool to try to improve comprehensiveness and continuity of care.

Resident:
Assessor:
Clinical Setting:
Date:
Skill Dimension:
Theme:
Language Skills - Charting Skills - Assessment should concentrate mainly on the charting of individual encounters. Overall organization and structure of the ongoing clinical record are important, but these are often predetermined and outside the control of the individual—they can be assessed, but in a different context. Note that these charting skills are formatted as a set of key features.

Key Features:

Other:
Feedback given (what was done well / suggestions for improvement):
 

Signed Resident:   Signed Assessor:  
Date:   Date:  


  
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