How to understand medical decisions

How to write a self-explanatory medical summary

The content of the summary below is chosen for simplicity and because no special medical knowledge is required to understand it. The resulting summary sets out findings (symptoms etc), diagnoses and treatments by showing how they are linked.

 

The first step is to write down what has been decided, which includes what is being done and what is to be done - The plan:

Plan:

 

a. Inspect wound daily until healed

b. Sutures inserted

c. Sutures to be removed after 5 days

d. Tetanus booster to be given

e. Not to be given penicillin for any future wound infection

The next step is to write down the diagnosis that explains each item in the plan:

Diagnoses:

 

1. Deep cut on right lower leg (explains a, b, c)

 

2. Risk of tetanus (explains d)

 

3. Allergy to penicillin (explains e)

The next step is to write for each diagnosis, the supporting symptoms and other findings.  Note that 'symptoms' are what the patient experiences, (e.g. pain, breathlessness), examination findings are what someone else sees or hears, test results are findings based on technology and 'needs and preferences' are the patient's wishes at that date for future outcomes:

This can be made easier by copying and pasting the following template, inserting the information and deleting any text in the template that does not apply:

The self explanatory summary would then look like this:

Typical example

Diagnosis: _________________

Outline evidence: Original symptoms on __/__/___ ( ), examination findings on __/__/___ ( ), test results on __/__/___ ( ), needs and preferences on __/__/___ ( ).  Latest symptoms, examination findings, test results on __/__/___ ( ).

Outline management: Advice:_____.  Treatments: _____.  Next assessment ____.

1. Deep cut on right lower leg

Outline evidence: Original symptoms on 15/09/16 (Sudden pain in lower right leg when out walking), examination findings on 15/09/16 (Blood on foot, deep, wide gaping cut on lower leg), test results (N/A ), needs and preferences on 15/09/16 (prevent further bleeding, infection and help healing).  Latest symptoms, examination findings, test results on 17/09/16 (wound clean, dry and sutures satisfactory).

Outline management: Advice: wound to be inspected each day until healed.  Treatments: sutures inserted 15/09/16 and to be removed 20/09/16.  Next assessment A&E 20/09/16.

 

2. Risk of tetanus

Outline evidence: Original examination findings on 15/09/16 (deep, wide gaping cut on lower leg, causal object and its original state of cleanliness not seen), needs and preferences on 15/09/16 (wishes to avoid tetanus, no history of allegy previously).

Outline management: Advice: explanation re above given, decision agreed.  Treatments: tetanus booster given 15/09/16.

 

3. Allergy to penicillin

Outline evidence: Original symptoms on 23/02/06 (generalised itchy rash after oral penicillin).

Outline management: Not to be given penicillin in future.

1. Deep cut on right lower leg

Outline evidence: Original symptoms on 15/09/16 examination findings on 15/09/16, test results (N/A ), needs and preferences on 15/09/16.  Latest symptoms, examination findings, test results on 17/09/16.

Outline management: Advice: reassured, decision agreed.  Treatments: sutures inserted 15/09/16 and to be removed 20/09/16.  Next assessment A&E 20/09/16.

 

2. Risk of tetanus

Outline evidence: Original examination findings on 15/09/16, needs and preferences on 15/09/16.

Outline management: Advice: explanation re above given, decision agreed.  Treatments: tetanus booster given 15/09/16.

 

3. Allergy to penicillin

Outline evidence: Original symptoms on 23/02/06.

Outline management: Not to be given penicillin in future.

The next step is to insert the symptoms, examination findings, test results, needs and references (if they are remembered).  These are shown blow in brown.  Otherwise, they can be inserted after reading the records, perhaps at a later date or with the help of a medical professional.  The more detailed self explanatory summary would then look like this:

The first step is to insert the items from the above plan (shown below in green) followed by dates (that are shown in blue).  Next insert the dates of the symptoms, examination findings, test results, needs and references without specifying the latter.  These dates alone will allow the relevant finsings to be located in medical records.