Please check my patient notes

[aimskyhigh]

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I'm following FA-CS format. Please, let me know what I need to improve on.

FA 5th edi- case 6.
HPI - Source of information is the patients mother. Pt is 10 yo F who was diagnosed with diabetes 1 month ago. Mother doesn't know which type of diabets. At the time of diagnosis, she had polyuria, polydypsia, polyphagia, & hyperglycemia. She is on insulin 2 times. 1 at meal time and 1 at bed time. At home mother gives the insulin injection & when out side child takes it herself. Child is concerend about the effect it will have on her social life & parents were shocked & worried about the diagnosis. Fasting glucose was 96, in the mornign it is in 100 & before meals it is more than 100. Her weight is 180 now, before she was loosing weight, but now it is normal. Denies any chest pain or palpitation, GU or GI symtomps, N/V, dizzines or confuion. ROS- negative except as above. Allergies - NKDA. Meds- Insulin. PMH/PSH- none. FH- None. Immunization - UTD. Growth/Developmetn-UTD, Birth History - NSVD

 

[Ismet]

"She is on insulin 2 times. 1 at meal time and 1 at bed time." - this is a very awkward way to phrase what you're trying to say. You can instead say something like "She checks her blood sugar before meals and at bedtime." As you know, if the blood sugar is in an acceptable range, she would not administer insulin.

"At home mother gives the insulin injection & when out side child takes it herself." - not necessary

"in the mornign it is in 100" - again, awkward. Do you mean "in the 100's"?

"Her weight is 180 now" - assuming you mean 180 lb and not kg (hopefully the kid isn't 180 kg...) but you can't just throw a number around without units.

"before she was loosing weight, but now it is normal" - again, very awkward phrasing. You could say something like "Initially pt lost weight but is now stable at 180 lb." You should find out how much weight she lost and over what time frame. Parents can freak out about 3 lbs lost in a month, or not think that 15 lbs loss in 2 weeks is a huge deal.

I highly recommend leaving 30 seconds at the end of your note to review for spelling errors. Incorporate that into your practice now. The spelling doesn't have to be perfect, but with 15+ errors, it gets distracting.