GlossaryNutrition · Management
Consultation notes
A written record of findings, decisions, and tasks agreed upon in each consultation.
Definition and context
A written record of findings, decisions, and tasks agreed upon in each consultation. This definition summarizes the main objective of the concept so that any reader can quickly identify how to apply it.
Includes diagnosis, plan, adjustments, education provided, and tasks for the patient. Facilitates continuity between sessions.
Why is it relevant?
Prevents loss of key information and enables precise, coherent follow-up.
Applied example
How to apply it in Almendra
- Record notes in Almendra at the end of each consultation and link them to the plan and reminders.
- Use templates to avoid omitting diagnosis, adjustments, and tasks.
- Share a brief summary with the patient if applicable.
Key recommendations
- Write at the end of the consultation while it is fresh.
- Be specific: diagnosis, plan, adjustments, tasks, and check-up date.
- Include detected barriers and how they will be addressed.
- Maintain a consistent format for quick reading.
- Protect privacy and restrict access to authorized personnel.
Frequently asked questions
How long should a note be?
Brief and structured; enough to reproduce decisions and next actions.
How do I avoid omissions?
Use templates or checklists and record immediately after the consultation.
Related terms
Next step
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