As someone who has the responsibility to document a patient's care, the last thing you want to do is create such a confusing record that no one can understand what you have written. One of the simplest rules to follow when dictating reports is to keep your sentences short and sweet.
- Don't try to document more than one major point per sentence.
- Always remember the KISS formula: "Keep it simple, stupid!"
The word "and" is extremely seductive. So is the temptation to keep inserting commas as you dictate. Unless you avoid these temptations, your work can quickly deteriorate into meaningless drivel.While grammatically plausible, the following sentence-long paragraph is an example of conversational-style dictation overkill:
"The patient is a 62-year-old, right-handed Caucasian female who has recently retired from her job as an administrative assistant, Level 2, for the Department of Parks and Recreation, lives at home with two cats, three dogs, a parrot, and an abusive lover, smokes two packs of cigarettes and drinks six beers per day, has a past history of chronic obstructive pulmonary disease, congestive heart failure, total abdominal hysterectomy, bilateral salpingo-oophorectomy, appendectomy, tonsillectomy, adenoidectomy, and comes to the Emergency Room complaining of nausea, vomiting, diarrhea, fever, chills, night sweats, and altered mental status while insisting that she is not depressed by the upcoming holiday season and its usual round of family obligations, which tend to put a great deal of stress on her relationship (often resulting in binge drinking and increasingly brutal bouts of domestic violence)."
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