Last Updated on August 19, 2026
Important Components in a Case Note
•
Heading
e.g. AM Review, PM Review / Seen by Dr ___ (MO / Specialist), Night Review, Transfer in Review e.g. current issues, further history, subjective progress, physical examination, plan
• Date and time
•
Details
• Make sure each continuation sheet has patient’s name & IC / RN
Reminders
• Case notes must be written
clearly
Ensure your handwriting is legible Do not forget to document down important points during review / round with superior so that others can understand what is happening
• 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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