Introduction Medical record keeping Legible; signed; dated; appropriate
Introduction What is casebased discussion and what areas it focus on? Focus Positive indicators Medical record keeping Legible; signed; dated; appropriate to the problem; understandable in relation to and in sequence with other entries; helps the next clinician give effective and appropriate care. Clinical assessment Understood the patient’s story; made a clinical assessment based on appropriate questioning and examination. Investigation and referral Discusses the rationale for the investigations and necessary referrals; understands why diagnostic studies were ordered or performed, including the risks and benefits in relation to the differential diagnosis. Treatment Discusses the rationale for the treatment, including the risks and […]