Recording Your Observations

It is vital to record your observations in a way which will enable you or others to recognise the pattern of disease clearly.

• It will help you to evaluate the case at the time of the consultation
  
  
• It will enable you or others to determine any changes which have occurred at subsequent consultations
  
  
• Accuracy of description will be essential if you need to refer to published descriptions of the disease or consult a specialist
  
  
• Ensure that you record your observations at the time of the consultation

A well-organised clinical record form will help you to do this.