Recording

N. R. COLLEDGE

Introduction 294

The purpose of the case record 294 The patient's right of access 294

The system 294

The history 295 The examination 298 Clinical diagnosis or impression 299 Plan 300

Information given 300 Progress notes 300

Conclusion 301

Previous chapters have illustrated the wealth of information that can be obtained front the history and physical examination. This information plays a key part in a patient's care so it is vital that it is recorded in a way that is concise and clear.

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