The difference between H & P and kliniske notater lies in their structure and how they organise clinical information.

H & P, which stands for History of Present illness, is a format that first details the patient's current complaint in a chronological manner and then sequentially documents their sykehistorie, examination findings, impression/diagnosis, and treatment plan.

This approach is commonly used in Australia and provides a comprehensive view of the patient's condition from onset to treatment.

klinisk notat, which is an acronym for subjective, objective, vurdering, and abonnement, is the note style widely utilised in the US and other regions. This format segregates the clinical information into four distinct sections: the patient's subjective description of their problem, objective data from physical examination and tests, the healthcare provider's vurdering or diagnosis of the condition, and the proposed abonnement for managing the patient's care. kliniske notater are favoured for their clear, organised approach to documenting patient care across various healthcare disciplines.

The distinction between klinisk notat and klinisk notat (Issues) notater lies in their approach to dokumentasjon and managing multiple patient concerns. The classic klinisk notat format is ideally suited for addressing a single, specific concern or symptom a patient presents with. It follows a straightforward structure, guiding the behandler.

On the other hand, klinisk notat (Issues) incorporates a Problem List or Issues List into the vurdering and abonnement sections, making it more effective for managing patients who present with multiple requests or problems. This modified approach allows for each issue to be assessed and addressed separately within the same dokumentasjon, ensuring a more organised and comprehensive abonnement for patients with complex or multiple healthcare needs. klinisk notat (Issues) is particularly useful in scenarios where patients have a variety of concerns that require distinct evaluations and treatment plans.

Beyond klinisk notat and H & P formats, HeiDi offers further customisation for clinical documentation through the mal section located on the right side of your screen.
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While klinisk notat and H & P are foundational for creating the initial consult summary displayed on the left panel, the mal section on the right allows for the use of preset maler or the creation of custom ones.

These customisable maler enable you to structure the clinical notat in a way that best fits your clinical approach, providing the flexibility to address diverse clinical scenarios. Moreover, this feature is not limited to kliniske notater; it also facilitates the creation of additional dokumentasjon such as henvisning and legeattester. For guidance on setting up and utilising these maler, please refer to our short tutorial available at this link.

HeiDi offers profession & spesialitatbestemte formats for your kliniske notater, such as adime for dietetikere and imist-ambo for paramedisinere. Make sure you have selected your right spesialitet in your settings!