Consultation records
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
Related pages
Create an account to add page annotations
Annotations allow you to add information to this page that would be handy to have on hand during a consultation. E.g. a website or number. This information will always show when you visit this page.