A clear, well-organized clinical record is one of the most important adjuncts to your patient care. Your skill in recording your patient's history and physical examination should evolve in parallel with your growing skills in clinical reasoning and your ability to formulate the patient's Assessment and Plan. Your goal should be a clear, concise, but comprehensive report that documents the key findings of your patient assessment and communicates the patient's problems in a succinct and legible format to other providers and members of the health care team. Note that a good record provides the supporting data for the problems or diagnoses identified.
Regardless of your experience, certain principles will help you to organize a good record. Think especially about the order and readability of the record and the amount ofdetail needed. How much detail to include often poses a vexing problem. As a student, you may wish (or you may be required) to be quite detailed. This helps to build your descriptive skills, vocabulary, and speed—admittedly a painful and tedious process. Pressures of time, however, will ultimately force some compromises.
Run through the following checklist to make sure your record is clear, informative, and easy to follow.
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