Full Description
Patients are increasingly accessing their own electronic health record, ushering medical chart notes out of the cloistered purview of clinicians and into the age of transparency. With the recognition that patients are reading what is written about them, there is a need for a comprehensive reference on best practices for writing medical notes in this new era.
The Patient-Centered Approach to Medical Note-Writing covers important topics including stigmatizing language, the electronic health record, the different parts of a typical medical note, mental health, substance use, difficult encounters, and how to address electronic communication such as test results and patient messages. This book serves as a vital reference for students, residents, fellows and practicing clinicians.
Contents
Introduction: Why this book?.- A History of Medical Charts: Who owns it and who is it for?.- Patient-Centered Language: General Principles.- The Chief "Complaint" and History of Present Illness.- The Problem List / Medical History.- The Social History, Substance Use, and Lifestyle Habits.
