History - pertinent to the condition, and any answers to direct questions.

Examination - significant findings, both positive and negative, and information obtained from objective measurements, such as blood pressure.

Diagnosis - in clear terms. The notes should mention how the conclusion was arrived at. Any uncertainties about the diagnosis and the steps taken to exclude these must be mentioned.

Information - about everything that was told to the patient, including risks and benefits of particular treatments.

Consent - details of patient’s consent and the discussion that led up to that consent.

Treatment - the type and dosage of drugs, the amount prescribed, and any other treatment that the clinician may have organized.

Follow up - the arrangements for future appointments, any referrals, etc.

PROGRESS - INFORMATION ABOUT HOW THE PATIENT RESPONDED TO TREATMENT.