Clinical Decision Log
Clinical Decision Log
Prepared by: [YOUR NAME]
Date: [DATE]
Department: Clinical Affairs
To record and analyze key decisions made during patient care. This log captures essential details about clinical issues, decisions, and their outcomes, supporting effective management and ongoing assessment of patient treatment and care strategies.
|
Date |
Patient Information |
Clinical Issue |
Decision Executed |
Follow-Up Actions |
|---|---|---|---|---|
|
08/01/2050 |
John Doe, 45, Male |
Elevated blood pressure |
Initiated new antihypertensive medication |
Schedule follow-up in 2 weeks |
|
08/02/2050 |
Mary Smith, 60, Female |
Persistent cough |
Ordered chest X-ray |
Review results and adjust treatment plan |
|
08/03/2050 |
Michael Brown, 30, Male |
Acute abdominal pain |
Admitted for further evaluation |
Consult gastroenterologist |
|
08/04/2050 |
Lisa Johnson, 50, Female |
Diabetes management |
Adjusted insulin dosage |
Monitor levels and schedule next review |
|
08/05/2050 |
Robert White, 55, Male |
Post-surgery wound infection |
Prescribed antibiotics |
Continue antibiotics and reassess in 1 week |
Notes & Reminders:
-
Document Decisions Promptly: Record each decision immediately to ensure accuracy.
-
Include Detailed Patient Information: Provide complete details to maintain context for each decision.
-
Clarify Rationale Clearly: Explain the reasons behind each decision to understand its basis.
-
Assess Outcomes Thoroughly: Note the effects of each decision to gauge its effectiveness.
-
Plan Follow-Up Actions: Ensure follow-up steps are clearly outlined and scheduled to maintain continuity of care.
