Patient Clinical Notes
Good clinical records will allow a clinician to reconstruct a consultation or patient contact without relying on memory.
This will include all important findings, both positive and negative, with details of any objective measurement such as blood pressure, peak flow, etc as well as history relevant to the condition including any positive and negative answers to direct questions.
The following key aspects of a consultation are also noted:
- Investigations – details of any investigations arranged
- Referral – details of any referral made
- Information – information given to the patient concerning risks and benefits of proposed treatments
- Consent – details of consent given to proposed investigations, treatments or procedures
- Treatment – details of the main doses of drugs, total amount prescribed, any other treatment organized with batch number and expiry date of any medications personally administered
- Follow-up – arrangements for follow-up tests, future appointments and referrals made
- Progress – any further consultations, how the patient’s condition has progressed.