how to write a clinical summary
A clinical summary is a document that is used to communicate key clinical information about a patient to other health care professionals. It is a concise, yet detailed, overview of a patient’s current condition and past medical history.
A good clinical summary should include the following information:
-Patient’s name and identifying information
-Chief complaint
-Presenting symptoms
-Past medical history
-Medications
-Allergies
-Recent lab results
-Any other pertinent information
When writing a clinical summary, it is important to be concise and to-the-point. It is also important to make sure that all of the relevant information is included.
