Slik blir legemiddelgjennomgangen på sykehjemmet synlig i journalen
Du har gått gjennom hele listen, seponert to preparater og justert en dose. Spørsmålet er om noen kan lese det ut av journalen i ettertid.…
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Author: John
The patient you have never met before – the medical record note at the emergency room
At the emergency clinic, every consultation starts from zero. The note you write is often the only thing others get to know about what happened. The time is a quarter past…
Revised cancer care pathways from September 1st – what does it mean for your referral?
All 26 standardized pathways have been reviewed again, and the changes to the pathway times take effect today. For you as the referring physician, there is one question that...
The one who sees the diabetic foot first: the foot care therapist's case note
The foot care specialist is often the first to notice the change – a small sore, an altered sensation, a red spot. For the observation to mean anything for the patient,...
The most private information in the medical record – the gynecologist's balancing act
Few areas in medicine see the patient share so much, so quickly. The medical record must capture it precisely – while treating it with the care the information deserves.
How the diabetes nurse maintains the connection between check-ups
Diabetes is not followed up in a single consultation, but in a hundred. Every note is a thread in a trajectory that can last a lifetime –...
The pediatrician, the child, and the parent: who should be heard in the medical record?
In the pediatric ward, there are always at least two voices to be heard: the child and the one who accompanied them. The medical record must capture both – without the gaze…
The rheumatologist and the structured follow-up: When the timeline is the treatment
Rheumatic disease is not treated in a single consultation, but over years of check-ups. Your medical record is the timeline upon which the entire treatment strategy rests. A patient with rheumatoid...
The geriatrician and the complex patient: Documenting the whole picture
Ten diagnoses, twelve medications, one human being. Your geriatric assessment ties it all together – and the medical record must manage to hold the whole picture. The patient is 84...
The healthcare worker and documentation in care: When what you observe must be passed on
You are the one who is closest to the patient throughout the entire day. What you notice must be passed on to those who come after you – and...
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