Adding after care instructions to patient charts

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damseljamie-huntress

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This post serves as an archive of the related group notices

**body of notice**
This is a mandatory change we are requiring from all of you in order to support an upcoming rollout of new role play. Read the attached notecard for full details. The gist of this is to make sure we are adding clear instructions on follow-up actions such as prescription refills, reevaluations, and referrals so that we can then play the follow up.

Please and thank you! If you have any questions, please ask any of your leads (princess.minnelli), (luccy.sands)

**Contents of attached notecard**

Adding after care instructions to patient charts allows us to role play more and have more interactions with our patients and each other. We all know that the treatment field of our chart system is for the actions we take during role play to make our patients better. Please continue to use the treatment section for this purpose, BUT ADD patient after care instructions to the end of the chart.

So what are after care and what should we be writing down? First I’ll list out some common after care instructions. Then, we will go through a mock example of a patient’s chart complete with the added after care instructions.

**Common after care instructions**
Think like a real medical professional. What would you want to see in a follow up visit with the patient? Be sure to make your instructions to the point as we are limited on the amount of text we can enter into the fields. There is a list of possible abbreviations at the bottom of this notecard to help you save on characters.

-Refer to physical therapy for (description of injury)
Use this when the patient has suffered a soft tissue injury or an injury whose healing may cause soft tissue issues. Broken bones, muscle pulls, muscle tears, any injury requiring a cast or immobilization, injuries which will cause a limp, injuries which will cause ongoing back pain

-Refer to psyc counseling for (suspected psychological malady)
Use this when the patient has suffered injuries or episodes that should be looked at by a psychiatrist. Trauma suffered from rape, torture, hostage situations, or being witness to intense situations should be referred out for psychological counseling. Similarly, patients who have attempted suicide or are suffering from hallucinations or other psychotic episodes should be referred.

-Rx refill for (type of drug)
Use this to indicate that you are authorizing a patient to have a prescription refilled.

-Reevaluation of (describe thing to reevaluate)
Use this when the patient has a severe injury that we would want to check on later. Deep stab wounds, severe concussions, spinal cord injuries, hip injuries, knee injuries, eye injuries. Make a judgement call in determining if the injury is severe enough to merit looking at again. You can also use this for any patient you just want to see a second time (wink wink… nudge nudge…).

**Mock patient chart**
This is an example of a chart. I know, I’m a wierdo and put dashes on each line… it’s just how I do.

Avatar Name: chanda feiri
IC Name: Roisin Fitzgerald
Age: 25
Sex: F
Blood type : AB Pos
Physical Assessment:
-Patient has extensive bruising on back-side with multiple hand prints
-Patient appears distraught and describes being assaulted by “two awesomely amazing bitches in white lab coats”
-Patient limping on right leg.

Treatment/Rx:
-Applied ice to butt.
-X-ray of right leg shows strained tendons, applied cast to immobilize.
-Rx Ibuprofen with refill to manage ass swelling.
-Refer to physical therapy to recover mobility in right knee.
-Refer to psyc counseling for trauma of assault by “two awesomely amazing bitches in white lab coats”

**The special exception of Asylum patients**
Those of us also working in the Asylum know that the standard referrals won’t always work for us. In the case of the Asylum, we need you to be more free form with your after care instructions. Please try and list concise instructions in the treatment section so that other staff can look at a patient file and continue with a patient’s treatment.

**Common medical abbreviations**
Pat = Patient
Rx = Prescription/Treatment
ER = Emergency Room
OR = Operating Room
Psyc = Psychologist/Psychiatrist/Psychology
BP = Blood Pressure
HR = Heart Rate
O2 = Oxygen
C/O = Complaining Of
DX = Diagnosis
FU = Follow Up
HO = History Of
ICU = Intensive Care Unit
L = Left
R = Right
OB = Obstetrics

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