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Learning about “the consultation” and developing from novice to expert starts early as medical students get to grips with the parallel tasks of understanding the first steps in clinical decision-making, learning the questions prompted by particular symptoms, and setting out to become good communicators. First attempts are invariably awkward, but as experience and knowledge accrue, it all comes together and a consultation that would take a first-year student hours can be accomplished in a third of the time by a Foundation doctor.
The outcome of that process is a note in the record that describes all the key findings and either then or later includes a record of the management plan. Over time the record is extended and includes notes about progress, response to treatment, and all events up to discharge from care. The record is thus a key document in communicating findings, discussions, decisions, plans and actions to everyone concerned in the care of that patient. Yet how much attention is paid to the quality of these notes?
Much emphasis is, correctly, paid to the …
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