MEDizzy
MEDizzy
Rebang Chakma
Rebang Chakmaalmost 5 years ago

How to follow up a patient?

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almost 5 years ago

Patient follow ups should be done systematically. We may be able to apply a SOAP based frame work however the workflow will be different based in your experience, style, intent, milieu, days list, and acuity. Things needs to be reviewed from the point that you last saw the patient, like consult notes, primary team notes, nurse notes, rehabilitation notes, nutritionist notes, etc. Review the vital signs including fluid ins/outs and weights (for volume sensitive patients/deplete, heart failure patients, post operative patients, burn patients, multi trauma or multisystem/critical care patients). Review labs and imaging studies that have resulted. Review any other bedside test results, and also consider interpretations of all these. Then check in with the nurse if possible and the patient. Allow time for brief bedside supportive open communication. Complete a focused ROS. Complete a focused physical, note any tubes, lines, and drains. Illicit from the patient if there were any specific other items that may need to be addressed or relatives or friends they would like notified. Formulate an assessment and plan and inform the patient of the key items and agenda for the day. Place order entries into the system. Complete the progress note. Check in with the patient later in the day and check in with their nurse, case manager, consultants, and if consented by the patient, their family.

almost 5 years ago

Dr.,M. Every two weeks six months too a year then post op pre op monthly follow up

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