A medical record provided by a doctor to a patient should contain the following information1, 2010):
- Name and registration number of treating doctor
- Name, demographic details and contact number of patient
- Relevant clinical history, assessment and reassessment findings, nursing notes, diagnosis
- Investigation reports
- Details of medical treatment, invasive procedures, surgery and other care provided
- Applicable consents
- Discharge summary
- Cause-of-death certificate & Death Summary (where applicable)
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