Medical Records 101

By , May 25, 2010 3:25 pm


Assess:  “Fell off couch & now limited movement, distressed with any attempt tomove (sic) arm.  Has croup like cough & black eye from cat.  PainStop @ triage.”

From this descriptive triage assessment, we can interpret:

1. That the child fell off the couch, and since that time is acting like a teacup.

2. Becomes distressed when no longer allowed to play that game.

3. Also has a cough.

4. And a black eye from the cat.  No need to try to make this funny.  That’s actually what they wrote.

5. Has given their contact details as

This triage assessment was initially confusing to me, until I read the doctor’s notes:

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Then it all made sense.

Brevity is the key to clarity.

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