chapter  3
70 Pages

Effective communication

You are reviewing a patient who has had an allergic reaction to penicillin. You treat the patient and document your history and examination in the notes. You mention the event to your senior house officer (SHO) when you next see them, which is at least three hours after the event. They ask you whether you examined their throat with a pen torch, which you did not. You return to the patient to re-examine them, and their throat looks normal. There have been several entries in the notes since your last one, and you are unsure how to enter this extra information in the notes.