Making medical records during consultations in the medical clinic

It is important to have informative medical recordings in the medical clinic to facilitate communication between and among physician colleagues (particularly in the setting of multiple physicians seeing one patient).  In addition, informative medical recordings are important to facilitate physician’s communication with the patients particularly if they are given a copy and an informed consent or agreement on management is to be obtained.

I have yet to see a primer on how to make an informative medical record in the medical clinic aside from the traditional recommended format of SOAP (Subjective – Objective – Assessment – Plan).
I am recommending the following essential contents of medical recording in the medical clinic (borne out of experience):
One can use a notepad or a whole bond paper.   One can use additional sheets if needed.
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Note: It is important that the handwriting is legible at all times.

 

Recommended Readings:


Different purpose categorization of medical clinic consultation
 

Physician Pad in my Clinic and How I Use It

 
 

 


ROJ@18dec24;25

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