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In this tutorial, David Keegan, an academic family doctor at the University of Calgary, discusses the fundamentals of writing clinical patient notes. He emphasizes the importance of understanding the purpose behind documentation. Writing notes serves to record the details of patient interactions, allowing healthcare professionals to recall what was discussed and the actions taken. These notes facilitate continuity of care, enabling other colleagues or health professionals to access vital information about the patient’s treatment. Additionally, proper documentation is crucial for legal purposes, ensuring a reliable account of the patient's care history.
