Tut how to ask questions and write notes

• Order:

  • Subjective
  • Objective
  • Assessment
  • Plan
• Consent pt 1

  • MUST BE DOCUMENTED EVERY SINGLE TIME (ALSO NOTE IF PATIENT DOESNT CONSENT)
  • must be voluntary - decision to either consent or not to treatment must be made by the person and not influenced by pressure from medical staff, friends or family
  • must be informed - the person must be given all the info about what the treatment involves, including the benefits and risks, whether there are reasonable alternative treatments, and what will happen if treatments doesnt go ahead
• Consent pt 2

  • must be capacity based - person must be capable of giving consent, which means they understand the info given to them and can use it to make an informed decision
  • if an adult has the capacity to make a voluntary and informed decision to consent to or refuse a particular treatment, their decision must be respected
• Objective:

  • be specific!
• Objective:

  • clinical reasoning is key
  • what do you need to assess and WHY
  • anything else you could consider for this patient in their objective section
  • if so, how would you document this