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Housemanship

Documentation of Case Notes

Last Updated on July 14, 2022

Important Components in a Case Note

Heading
• Date and time
Details
• Make sure each continuation sheet has patient’s name & IC / RN

Reminders

• Case notes must be written clearly, adequately and precisely
• Case note is a legal documentation and it is also a form of communication among colleagues / with other teams or departments
• Do not use uncommon abbreviations
• Avoid using abbreviation if you think that particular abbreviation may cause confusion to others

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