How to Write Clinical Patient Notes: The Basics

44 thoughts on “How to Write Clinical Patient Notes: The Basics”

1. They're on IG

2. Thanks to one of the comments below I just got a hospital release note for work and it was easy getting it done with Cyber credible 👍👍

3. They're on IG

4. Thanks Cyber always reliable platform I was able to use the hospital release note for work

5. Heres the thing: courts and juries dont like medical terminology. Aim to write in a way that avoids unecessary technical terminology.

6. I feel so dumb. I just got a job and I’m not good at writing the chief complaint. I just got out of school and this is my first job. I need to work on this ASAP!! What do you recommend?

7. They're on IG

8. ❤❤ hi, great channel you have here! striving my best to create good revision videos for medical students as well 😄

9. Thank you so much

10. Thank you

11. 7

12. THEY ON INSTAGRAM

13. Thanks to cyber credible I will never doubt your amazing work💯

14. I was really having a hard time getting my patient note last week😓😓 but I’m all good and that’s #Cybercredible# work 👍

15. Is there any test when after hypothesis ?Do we need to anything when diagnosis ?After that,just straightly to give a plan to patient ,and give the medication or something ?

16. 🔴
    https://youtu.be/L6-_YpKQPws

17. ❤❤❤❤

18. Great sir

19. thanks Doc!

20. Thank you

21. There aren't many videos on this topic. If you could make a video on how to document a treatment plan accurately especially for Ob-Gyn patients, this would be really helpful. Thank you for your efforts, really appreciate it.

22. Thank you

23. Urdu me

24. Thank you!! Great demonstration. Will definitely remember the SOAP acronym!

25. Great work Dr, our Practice at Illovo follows you vigorously and gas for years

26. Perfect thanks dia dia

27. I’m a patient and unfortunately some doctors do not make accurate notes I’ve even had some letters where I’ve been called him/he and the wrong name! It’s really upsetting I hope more doctors watch this and improve their note taking. Getting inaccurate reports of what happened can be unnecessarily upsetting.

28. Fabulous recording quality with practical information, thanks a lot!

29. Sir can you explain how to write a referral OPD slip to higher center

30. What if it is the spouse talking about signs of the patient. What do I do with that do i use that in the soap notes or leave it out. Noone talks about that

31. God bless you

32. where i come from we add I and E , making the abbreviation spelled as S O A P I E. I for implementation and E for evaluation… but i find this simple and straight forward thanks… watching 2020

33. Great overview! Diagnosis specificity, acuity, type and etiology are of paramount importance for USA inpatient notes. Possibly probably Dx help for inpatient notes even though not coded for outpt.

34. Did this in RN school. Used this in Health Unit Coordinator.

    What the patient describes–Subjective and what you observed–objective.
    Assessment–a hypothesis about what you think is the issue/diagnosis/differential diagnosis
    Plan–Management of care/consultation

35. ❤❤👍

36. Thank you. 🥺💜

37. The link sucks lmaaoooo

38. thank you ! 🙂

39. ❤💛💙

40. Is it also same for how to make a patients protocol

41. one day in the future I would love to meet you and thank you doctor for your efforts!

42. Question, if you are working under a physician as a tech, and the machine you are using on the patient is not printing out patient identifiers or timestamps which are critical in this type of test, and the doctor wants you to sign your name to this report knowing that the hard copy of the report is incomplete what would you do?

43. excellent talk, focussed and precise

44. good information to my research .

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