anyone have a good resource for dictating complete clinic notes or op notes? we're just being thrown to the lions with 'go dictate this' and then we do these crappy notes. a template would be nice.
I remember that my first dicatation sucked too. I rambled too much and forgot important information in op notes.
For me, I was lucky that I started at a community hospital and the attendings did the first couple dictations. I copied out the dictations for common procedures that I was going to be doing and put them in my palm pilot. When you are more comfortable, you can decide what you like and make alterations in your dictations.
If you're being thrown to the wolves, print out the previous op notes when you admit someone to the hospital, or when another resident dictates a note, print it out.
As far as clinic notes, most don't need that much detail, just hit the high points in a SOAP format.
anyone have a good resource for dictating complete clinic notes or op notes? we're just being thrown to the lions with 'go dictate this' and then we do these crappy notes. a template would be nice.
Hi there,
The Surgical Intern Pocket Survival Guide by Chamberlain has sample dictations for all the common surgeries and templates for everything. It is inexpensive and fits in your pocket. Costs about $8.
Current clinical stratagies: Surgery also has sample dictations, pre-op/post-op notes, and all sorts of other useful stuff for all major gen-surg diagnosis. Costs about 15 smackers.