It is extremely important to always write good clinical notes.
- The patient’s notes are the best way of reminding yourself at the next visit what the problems were, what was found and decided upon, and what investigations and management were planned.
- Good notes are the best way of communicating this information to other members of the health team who may see this child at future visits.
- Writing good notes helps one to think and develop a clear idea of the child’s problems and the required management. By looking at other colleagues’ notes it is easy to determine whether they had a clear idea of the problems and course of action needed.
- The patient’s notes are the official record of the patient’s care. They are the medico-legal record of the interaction between the patient and the health service.
- Keeping good notes helps to develop and maintain a high level of care and pride in the service.
It is essential that clinical notes can be easily read and understood. It is a waste of time and dangerous practice to make notes which others are unable to read.
It is extremely important always to write good clinical notes.