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GIFTED AND TALENTED HANDBOOK 201720181Table of Contents Note: Each category below is hyperlinked to that section in the handbook. Click on the category title within the handbook to return to the Table

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1. Start by writing down the date and time of the note.
2. Begin with the patient's personal information, including their full name, date of birth, and contact details.
3. Note down the reason for the visit or appointment, describing the symptoms or purpose of the note.
4. Document the patient's medical history, including any pre-existing conditions, allergies, or previous treatments.
5. Record the vital signs and measurements, such as blood pressure, heart rate, temperature, and weight.
6. Include details about the examination, diagnosis, and treatment provided.
7. Write down any prescribed medications, dosage instructions, and duration of treatment.
8. Document any additional instructions or recommendations given to the patient, such as dietary restrictions or follow-up appointments.
9. Sign and date the note to authenticate it as part of the patient's medical record.
10. Review the note for accuracy and completeness before saving or submitting it.

Who needs note each category below?

1. Medical professionals, including doctors, nurses, and healthcare practitioners, need to fill out note each category below.
2. Hospital administrators and staff responsible for maintaining patient records also require these note categories.
3. Insurance companies and legal entities may need access to these notes for claim processing or legal purposes.
4. Patients themselves may also request a copy of their medical notes for personal reference or to share with other healthcare providers.

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