TableĀ 2

Structured information which needs to be included in clinical records

Clinical notes should include
Patient demographics
Reasons for the current visit
The scope of examination
Positive exam findings
Pertinent negative exam findings
Key abnormal test findings
Diagnosis or impression
Clear management plan and agreed actions
Treatment details and future treatment recommendations
Medication administered, prescribed or renewed and any drug allergies
Written (or oral) instructions and/or educational information given to the patient
Clear documentation and justification for resuscitation status and ceiling of care (if inpatient)
Documentation of communications with patient and family/friends (level of awareness of the situation and acceptance of the plans)
Recommended return visit date