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Writing in a patient’s notes is something you’ll be required to do at some point during your training, so it’s important that you’re aware of how to document appropriately. Accurate documentation is also incredibly important from a medicolegal perspective with the phrase “If it isn’t in the notes, it didn’t happen!” often referenced when discussing the issue. This guide provides an overview of the process of documenting in a patient’s notes and hopefully should make you feel a little more prepared when you have your first attempt on the ward.

The basics

Ok, so a blank continuation sheet has been thrust towards you and you’ve been asked to document something- let’s remind ourselves of the basics of documentation.

What should I use to write with?

You need to use a pen with black ink (as this is the most legible if notes are photocopied).

 

Patient details

For every new sheet of paper your first task should always be documenting at least three key identifiers for a patient:

  • Full name
  • Date of birth
  • Unique patient identifier
  • Patient’s home address

If a patient label containing at least 3 identifiers is available then this can be used instead of writing out the information yourself.

Location details

You should indicate the patient’s location on the continuation sheet:

  • Hospital
  • Ward

Patient identifiers

Making a new entry in the notes

At this point you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top.

How to make an entry in a patient’s notes

1. Add the date and time (in 24hr format) of your entry 

2. Write your name and role as an underlined heading

3. Make your entry in the notes below this heading (see our other documentation guides for more detail on making different types of entries in the notes)

4. At the end of your entry to need to include the following:

  • Your full name
  • Your grade/role (e.g. Medical student/F2/Neurology registrar)
  • Your signature
  • Your professional registration number (e.g. GMC number)
  • Your contact number (e.g. phone/bleep)

Documentation example

Other things to be aware of…

What if your entry spans more than one page?

If your entry in the notes happens to span more than one page:

1. Write “continued on next page” or “continued” with an arrow pointing off the page after the entry on the first page

2. Write your name, signature, professional registration number and contact number at the end of this partial entry

3. Add the patient’s name, date of birth and unique identifier to the new page

4. Write the date and time of the entry on the second page

5. Write your name and role, followed by the word “continued” as an underlined heading

6. You can now continue the entry from the previous page

7. At the end of this entry you need to include all of your details as shown in step 4 of the previous section

Although this might seem tedious it’s actually really important, as it ensures the chronology of your entry is clear to others reading it later.

What if you are too busy dealing with sick patients to write in the notes at the time?

You should always try to document your patient encounters as promptly as possible to reduce the risk of you forgetting key details and also to ensure other team members are aware of any changes to a patient’s condition or management plan. However in reality this isn’t always possible, for instance if you’re dealing with an acutely unwell patient you need to prioritise their management over the documentation of the sequence of events.

When you return to the patient’s notes at a later time you need to:

1. Ensure the continuation sheet has the patient’s 3 key identifiers as previously described

2. Document the current time and date of your entry

3. Write your name and grade as an underlined title

4. Begin the entry by stating that this is written in retrospect, with the time the entry is referring to documented

5. Complete the entry in the notes

6. At the end of this entry you need to include all of your details as shown in step 4 of the making an entry in the notes guide above.

Written in retrospect example

 

What if I write something incorrectly in the notes?

If you make a mistake whilst making your entry (e.g. factual error/spelling error):

  • Simply cross the mistake out with a single line through the erroneous words
  • Write your signature in addition to the time and date beside the area crossed out
  • Do not use Tipp-Ex to erase the errors
  • Do not excessively scribble over the errors to make them unreadable

Example of error correction

Filing the documentation appropriately

You should ensure that you file your documentation in the appropriate place within a patient’s notes, this differs significantly between hospitals, so always ask the team if you’re unsure.

Make sure to put the patient’s notes back in the appropriate trolley or storage area on the ward once you’re finished.

Summary

Hopefully that was a useful overview of the basics of documenting in patient notes. We’ve got more guides discussing other aspects of documentation in more detail which you can check out here. If you have any documentation tips of your own you’d like to share just comment below and we’ll try our best to incorporate them 🙂.

References

1. Royal College of Physicians – Generic medical record keeping standards. 30th June 2015. [LINK]

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