How detailed should your notes be?

This depends on whether you are seeing the patient for the first time or at a follow-up clinic. It also depends on the amount of time you have to examine the infant and write notes. Notes must be written at every visit. The aim is to produce the best notes possible under the circumstances.

Usually, detailed notes are written at the first consultation. Thereafter, a brief note should be made about each problem on the problem list at every visit. Do not lose a problem from the list until it has been fully attended to. Always make a note of any problems in the Road-to-Health Card.

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