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5A Skills workshop: Clinical notes and observatio

5A Skills workshop: Clinical notes and observations

Objectives

When you have completed this skills workshop you should be able to:

Write good clinical notes.
Record routine observations.

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Item Title

5-a The date and time

5-b Always sign your notes

5-c The ‘soap’ method of writing notes

5-e The observations

5-f The assessment

5-g The problem list

5-h The management

5-i An example of good ‘soap’ notes

5-j An example of poor notes

5-k Problem-orientated patient record

5-l A common patient record

5-m Abbreviations

5-n The observation chart

5-o Using an observation chart

5-p Recording fluid intake

5-q Recording fluid output

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Results 1 - 17 of 17

Introduction ( 0 items )
1 Neonatal asphyxia and resuscitation ( 34 items )
1A Skills workshop: Neonatal resuscitation ( 15 items )
2 Assessing gestational age and size at birth ( 29 items )
2A Skills workshop: Gestational age and weight ( 10 items )
3 The routine care of normal infants ( 46 items )
3A Skills workshop: Clinical history and exam ( 12 items )
4 Feeding normal infants ( 46 items )
5 Care of high-risk and sick infants ( 38 items )
6 Feeding sick or high-risk infants ( 35 items )
6A Skills workshop: Feeding sick or high-risk infants ( 12 items )
7 Temperature control and hypothermia ( 21 items )
7A Skills workshop: Temperature control and hypothermia ( 14 items )
8 Glucose control and hypoglycaemia ( 23 items )
8A Skills workshop: Glucose control and hypoglycaemia ( 12 items )
9 Jaundice, anaemia and polycythaemia ( 42 items )
9A Skills workshop: Jaundice and phototherapy ( 8 items )
10 Respiratory distress and apnoea ( 44 items )
10A Skills workshop: Respiratory distress & apnoea ( 13 items )
11 Oxygen therapy ( 52 items )
11A Skills workshop: Oxygen therapy ( 16 items )
12 Infection ( 55 items )
13 Trauma and bleeding ( 33 items )
14 Birth defects ( 33 items )
15 Communication ( 39 items )

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