Clinical Records and Consultation Evidence

Start the correct record

1. Open the patient from today's queue and verify name, patient number, age and reason for visit.
2. Confirm the consulting nurse before capturing clinical information.
3. Check general consent and any procedure-specific consent required for today's care.

Capture the clinical encounter

1. Record the presenting complaint and relevant subjective history.
2. Record objective observations, examination findings and vital signs where applicable.
3. Record the nursing assessment or diagnosis, plan, treatment and medications actually supplied or prescribed.
4. Use clinical notes for relevant context; do not replace structured fields with one large note.

Tip: Use clear, factual language and distinguish what the patient reported from what the practitioner observed.

Complete and verify

1. Review the record before selecting Complete consultation. Correct omissions while the encounter is still open.
2. Open Patient records or Recent consultations and confirm the saved nurse, assessment, treatment, medication and consent evidence.
3. If a value is shown as None, confirm whether it was intentionally not applicable or accidentally omitted.