Home›Specialties› General Medicine

General Medicine

Clinical documentation standards for internal medicine.

Documentation Overview

General medicine documentation requires systematic, problem-oriented records that accurately reflect the patient journey from admission through to discharge. Documentation must support clinical decision-making, care continuity and medico-legal requirements.

Key Documentation Standards

  • Structured clerking using presenting complaint, HPC, PMH, DH, SH, FH, Systems Review, Examination, Impression, Plan
  • Daily ward round notes documenting observations, active problems and plan
  • Timely discharge summaries — ideally on day of discharge
  • Clear escalation and ceiling of care documentation
  • NEWS2 recording with appropriate response documentation
  • Fluid balance and medication reconciliation at all care transitions

Common Documentation Scenarios

  • Acute medical take — structured clerking with differential diagnosis
  • Complex multimorbidity — problem-oriented ward round notes
  • Long-term condition review — structured clinic letters
  • Palliative and end-of-life — advance care plan documentation
  • Deteriorating patient — escalation documentation and SBAR communication
  • Discharge to community — comprehensive discharge summary

Relevant Templates

Quick Reference
GENERAL MEDICINE DOCUMENTATION CHECKLIST
=========================================
ADMISSION
□ Clerking completed within 4 hours
□ Allergy status documented
□ Drug history reconciled
□ NEWS2 recorded
□ Escalation plan documented
□ Ceiling of care discussed

WARD ROUNDS
□ Date and time on every entry
□ Observations reviewed
□ Active problems listed
□ Plan for each problem
□ VTE status reviewed
□ Discharge planning noted

DISCHARGE
□ Summary completed on day of discharge
□ Medication changes with reasons
□ Pending results flagged for GP
□ Follow-up arranged
□ Patient information provided
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.