consultation records
Last reviewed 01/2018
An accurate, legible and appropriate record of every doctor-patient encounter and referral should be kept.
The information recorded should include at least:
- the date of the consultation
- relevant history and examination findings
- any measurements carried out (blood pressure, peak flow, weight etc)
- the diagnosis or problem
- an outline of the management plan
- investigations ordered
- follow-up arrangements
If a prescription is issued, a record should be made of the:
- drug name
- dose
- quantity
- special precautions given to to patient