The short answer
Make the status of each investigation clear. Was the test considered, ordered, performed, resulted or still pending? Record the result and units when they are available, then explain in the plan who will act on an outstanding result. A test you intend to order must not appear as a normal result.
Give every test a clear status
An ultrasound can be considered, ordered, performed or reported as showing no effusion. Those are four different stages, and the note should reflect the one that actually occurred. An empty investigations heading is not a reason to invent a result.
A pending result belongs in the investigation section as pending, with the relevant follow-up action in the plan. State who will review it if that was decided.
Preserve values, units and sequence
When a result changes over time, keep the first and repeat measurements distinct. For example, “Initial glucose 2.7 mmol/L; repeat glucose returned to normal range” shows the sequence that “glucose normal” hides. Check decimals, units and whether the value rose or fell.
For an ECG, distinguish the doctor’s interpretation from a prior report. Check the specific findings that support a stated conclusion instead of compressing several observations into “ECG normal” if the details matter.
Check that the plan matches the results
The assessment can interpret available findings, but uncertainty should remain explicit. If a viral panel, culture or thyroid study is outstanding, the note must not imply a confirmed negative test. The final plan should show what happens next if the result changes care.
Common questions
Should pending tests be omitted?
No. Record them as pending and include the actual follow-up plan when known.
Can “normal bloods” replace every value?
Only if that accurately preserves the clinically relevant source. Keep important values and trends.
Sources and product details
These guides describe DictaMed’s current workflow and general documentation principles. Follow your workplace policy and use clinical judgement for each patient.