Common symbols and diagrams used in the medical notes

This is one thing I'm going to miss with electronic record, drawing pretty pictures.

Good guide!

Glad to see your drawings and hand writing are as child-like as mine
Enjoying the insights, thanks Matt.

Originally Posted by JeremiahGreenspoon

Glad to see your drawings and hand writing are as child-like as mine
Enjoying the insights, thanks Matt.

For a brief moment I wondered if I needed to be embarrassed about my writing and drawings, but then I thought about it and decided so long as their legible I'm doing pretty well. :P I embrace printing over cursive!

When reading charts this is the type of writing I prefer over cursive or random scrawl.

Mine looks similar to this actually too

Great work! This is awesome!

What do the top two mean? These remind me of those Gotcha puzzles with the pictures which symbolise words!

Originally Posted by ashllis91

What do the top two mean? These remind me of those Gotcha puzzles with the pictures which symbolise words!

The top left describes heart sounds I, and II and what you hear during systole or diastole. The top right is a pictorial depiction of the lower limbs. The plus signs at the knees and ankles represent reflex strength (++ = normal, + = reduced). The downward arrow represents the plantar reflex (which can be up or down, normal is down). Of note, +++ = hyperreflexic and (+) = only elicitable with reinforcement manoeuvres.

Originally Posted by Matt

The top left describes heart sounds I, and II and what you hear during systole or diastole. The top right is a pictorial depiction of the lower limbs. The plus signs at the knees and ankles represent reflex strength (++ = normal, + = reduced). The downward arrow represents the plantar reflex (which can be up or down, normal is down). Of note, +++ = hyperreflexic and (+) = only elicitable with reinforcement manoeuvres.

You sound like a doctor now! I remember back in the day, a year or two ago, you didn't have that ...academic assuredness? Well done, am enjoying the pretty pictures and well-thought out explanations too.

As a matter of interest, I know that nurses are authorised to write in the medical notes/clinical notes of patients, however are there any restrictions? Say 10 years from now I'm a CNS (Clinical Nurse Specialist) can I diagnose in the notes or will that only be allowed with completion of NP?

Sorry Matt. Probably irrelevant. Anyways...nice work!! :-)

It's not a matter of whether a nurse can diagnose or not, more that diagnosis, as a nurse, would be irrelevant to nursing note entries. Without trying to sound patronising, nobody would take any notice of it anyway. That's not a nurse's job.

We draw love hearts and then, ironically, the crossed line that you see on the lungs, to signify that the heart is fine (as in, not a broken heart)

My first ever registrar was a cardiology advanced trainee and wrote like <3 reg as her title in the notes. A surgeon once asked what she'd write if she were a urologist :P

Originally Posted by Matt

It's not a matter of whether a nurse can diagnose or not, more that diagnosis, as a nurse, would be irrelevant to nursing note entries. Without trying to sound patronising, nobody would take any notice of it anyway. That's not a nurse's job.

Feel free to sound patronising... I'm used to being patronised anyway! You're right though... diagnosing isn't a nurse's job, just like how assisting patients with their activities of dailing living such as eating and showering isn't the job of a doctor, I suppose. I should try to think things through more thoroughly before posting.

Have you started working as a JMO yet Matt? How are you finding it?

Im trying to understand how to write med notes for first year but this seems hard to understand - but awesome idea nonetheless :P