What is the Point?

Having been on the road now for a few weeks, I am starting to come across things, which I have seen and experienced before.

So now, when the circumstances are right, I am trying to improve my performance. Commendable, I hear you shout.

Well is there any bloody point?

We fill a standard set of paperwork in for every patient we see and having done this a good few times now, I wish to improve the way I fill in the forms. 90% of the form is tick type boxes or boxes to put in patient observations; i.e Pulse, Oxygen saturation, Blood Pressure etc.

This means that it does not require a great deal of free thinking, just accurate observations.

There is however, one blank, free text space. (the size of three 1st class stamps by the way!) to write the history and what you discovered, in your own words. There is also a method of taking patient history and observations, called the Medical Model. This is similar to Doctor's notes in hospital and ensures that we are all speaking the same language. This is made up of the following sections and abbreviations;

PC = Presenting Complaint (why we are there)
HxPC = History of Presenting Complaint (what let up to them calling us - symptoms etc)
PMH = Previous Medical History
Allergies
DH = Drug History
SocHX - Social History (Their living circumstances)
FamHX - Family History (genetic predispositions to disease etc)
O/E = On Examination (what I found when I examined the patient)
Plan = Treatment plan

Now all that information above cannot be squeezed into the little free text box we get, so there is a nice A4 continuation sheet available to record all that valuable information and patient history on.

I completed this in detail for a patient yesterday and after completing a comprehensive verbal handover to the A&E staff, I duly gave a copy of the paperwork to them.

Imagine my surprise, when on being called today to move the same patient from the hospital to the hospice and being given a copy of his notes from his 1 day hospital stay, I could not find any record or copy of anything I had written on the 30min journey to hospital, when he was at his most ill.

I am not even sure if any of the Doctor's or Nurses had even referred to it during his treatment and probably asked the poor Gent all the same questions I had.

Why bother??