History-talking and annotation of notes

Fortunately in general surgery the patient's problem is often abvious, eg:- I have a lump in my groin, ' I have terrible pain in my stomach. Nevertheless it is important to establish clearly:

• The Presenting complanit, its time of onset and progression, eg- better or worse.
• A previous history of similar problems.
• The past medical and surgical history including any operations.
• The name and nature of any drugs taken by the patient.
• The family and social history.

There is usually enough time even in emergencies to establish a clear history of the functioning of the body systems, picking up any gross abnormalities.
Annotation of notes

• Make your notes brief and to the point. Write legibly. Increasingly, Many departments have an admission protocol with questions to which boxes are appended. As each question is answered the boxx is ticked. The data allows the records to be computerzied and facilitates surgical audit.
• When decribing significant features found on examination use simple line drawings  to illustrate the point.
• When you go on your ward round write a brief update of your patien'ts condition.
• Record any changes in your patient's condition in the notes.