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
Can You Spot an Error?
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