The basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules Record all pertinent data, avoid extraneous data · Use standard format Describe comprehensively, use common terms, avoid nonstandard abbreviations Written in an all-round way, all items should be filled the hand writing should be clear, not scratchy or be altered Be objective. use diagram when indicatedThe basic requirement of clinical records In writing up the history and the physical examination, the examiner should obey the following rules: • Record all pertinent data, avoid extraneous data • Use standard format • Describe comprehensively, use common terms, avoid nonstandard abbreviations • Written in an all-round way, all items should be filled, the hand writing should be clear, not scratchy or be altered • Be objective, use diagram when indicated