Recording Your Observations
It is vital to record your observations in a way which
will enable you or others to recognise the pattern of disease clearly.
- It will help you to evaluate the case at the time of the consultation
- It will enable you or others to determine any changes which
have occurred at subsequent consultations
- Accuracy of description will be essential if you need to refer
to published descriptions of the disease or consult a specialist
- Ensure that you record your observations at the time of the
consultation
A well-organised clinical record form will help you to do this.
|