Use the five-part visit summary and keep medication details explicit: dose, frequency, duration, and response.
Use a five-part summary: complaint-checks-conclusion-treatment-review. In treatment, explicitly record medication name, dose, frequency, duration, and cautions. In review, record target time and observation indicators.
Medication records should avoid two pitfalls: unclear dosage units, and missing logs for missed/changed doses. Prefer an execution checklist: drug + dose + frequency + start/end date, plus short reaction notes by day or key checkpoints.
For chronic management or long-term medication, include explicit recheck reminders and add same-day comparison summaries to close the loop.