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Consultation records

Authoring team

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

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The content herein is provided for informational purposes and does not replace the need to apply professional clinical judgement when diagnosing or treating any medical condition. A licensed medical practitioner should be consulted for diagnosis and treatment of any and all medical conditions.

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