need your advice on this patient notes please,thx - medicdoc

[ArchivalUser]

25 Yo M C/O L side chest and LUQ pain after MVA last night. The pain is 8/10, increased by deep breath and nothing is relieving. He reports productive cough and low grade fever and SOB. No loss of consciousness and no fluids from nose or the ear. Denies being under the influence of ETOH or illicit drugs. ROS is negative except as above. No medication and no drug allergies. Had Hx of IMN 2wk ago. Non smoker but drinks 3 beers on the weekend and no illicit drugs.

[ArchivalUser]

the only info about the pain is 8/10 and what makes it worse , what about , description , radiation, constant or not ????since its MVA , when, where and how that happened , did he seek and medical treatment last night ???
cough and fever, when did it start???? before or after the mVA



u r note is very short and has very little info about the pt ....need more info
whats up with PE and DD, workup

[ArchivalUser]

thanks for reply , PE, DD and workup is fine my problem is Hx that's why I'm looking for advice difinitly need more practice, the problem is I asked these Qs when I pracrtice with cs partner but when it comes to write the pt notes I always forget alot of stuff, my exam is in 2 wk and I worked on pt notes typing to improve my speed for 4 months but I'm facing 2 problem now speed and remembering every thing I don't know what to do else plz advice me if you know. thanks

[ArchivalUser]

the best way to remember thing s , is good note taking , my advise if u can organize u blue sheet into sections, one for CC, another for Positive signs, another for history and one for pe...make sure do that in order so when u come to write u r note ...u just follow a line / order of info from CC, to signs , to hx and end with u r PE ...give u r self an hour or two to find the best out line for the blue sheet that makes it easy for u

GL