Record-keeping (general practice)

An accurate, legible and appropriate record of every doctor-patient contact and referral should be kept The minimum information recorded should include: - the date of the consultation - relevant history and examination findings - any measurements carried out (blood pressure, peak flow, weight etc) - the diagnosis or problem - an outline of the management plan - investigations ordered - follow-up arrangements If a prescription is issued, a record should be made of the: - drug name - dose - quantity - special precautions given to to patient