De decursusThe progress note

Unit 25Level A2+Block 4 · De werkvloerSound of this unit: melodie van de lange zin

What this unit teaches

The passive: who did it does not matter

In block 2 you learned to recognise the passive; here you have to produce it. A Dutch record is not a story about you: it records what happened, in an order the next person can follow. Your own language may put the doctor in the sentence — «I saw», «I decided» — and doing that here reads as opinion rather than observation.

Er is bloed afgenomen.
De patiënt is besproken in het overleg.
De dosering is opgehoogd naar tweemaal daags.
worden + voltooid deelwoord · is/zijn + voltooid deelwoord

The four steps of a note

Subjective, objective, conclusion, plan — always in that order, every day. The order is not a style preference: the next reader searches by it. Hold it and a note takes ten minutes; abandon it and the same content takes half an hour and still gets questions.

S — wat de patiënt aangeeft:   «Pt. geeft aan dat de pijn is afgenomen.»
O — wat is waargenomen:        «Buik soepel, wond schoon en droog. T 37,2.»
C — de conclusie:              «Rustig beloop na operatie.»
B — het beleid:                «Pijnstilling continueren, morgen beoordelen.»

Written connectors, not spoken ones

These pairs mean the same thing and are not interchangeable: the left column in a record reads as careless, the right column in speech reads as pompous. Learn them as pairs from the start — you need both columns, in opposite places.

spreektaal      status
maar        →   echter
want / omdat →  gezien · in verband met
ook         →   tevens
trouwens    →   overigens
zoals afgesproken → conform afspraak

From the text

Het is drie uur. De dienst is bijna voorbij.
It is three o'clock. The shift is nearly over.

Vocabulary in this unit (66 words)

Dutch	Meaning
de decursus	progress note
het dossier	file, patient record
vermelden	to state, record
de aantekening	note
het verslag	report
de opbouw	structure, build-up
subjectief	subjective
objectief	objective
de bevinding	finding
waarnemen	to observe
de waarneming	observation
constateren	to establish, find
aangeven	to indicate, state
beoordelen	to assess
de beoordeling	assessment
de conclusie	conclusion
het beleid	management plan
evalueren	to evaluate, review
de evaluatie	evaluation, review
continueren	to continue
staken	to discontinue
ophogen	to increase (a dose)
verlagen	to lower
afnemen	to decrease; to take (a sample)
toenemen	to increase
het beloop	course (of illness)
ongewijzigd	unchanged
wijzigen	to change (formal)
de wijziging	change
ten opzichte van	compared with
in overleg met	in consultation with
aanvullend	additional
overigens	incidentally, moreover
tevens	also (formal)
echter	however (formal)
namelijk	namely, that is
conform	in accordance with
blijkens	as appears from
blijken	to appear, turn out
volgens	according to
in verband met	in connection with, due to
met betrekking tot	with regard to
gezien	in view of
de lijdende vorm	the passive voice
navolgbaar	traceable, reproducible
leesbaar	legible, readable
voluit	in full
de afkorting	abbreviation
schrijven	to write
later	later
de opvolger	the next person on shift
terugkeren	to return
teruglezen	to read back
nalezen	to read up, check afterwards
informeren	to inform
inzetten	to initiate, deploy
uitvoeren	to carry out
mobiliseren	to mobilise (a patient)
de begeleiding	supervision, guidance
de pijnstilling	pain relief
soepel	supple, soft
kortademig	short of breath
de dienstdoende	the doctor on duty
verschillend	different
het verschil	difference
voorbij	over, past

The first unit is free — no account needed.

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