11/13/24, 7\:40 PM Guide | Documentation basics

Documentation basics

Table of contents

Introduction

The ability to write in a patient's notes e
documentation is also incredibly important from a medicolegal perspective. This guide provides an overview of how to write in
a patient's notes and should hopefully make you feel a little more prepared when you have your

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
Full name
Date of birth
Unique patient identi
Home address
If a patient label containing at least three identi
manually.

Location details

You should indicate the patient's current location on the continuation sheet\:
Hospital
Ward
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Patient identi

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 identi

How to make an entry in a patient's notes

1. Add the date and time (in 24-hour 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).
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)
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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 " c o n t i n u e d o n t h e n e x t p a g e" or " c o n t i n u e d"
with an arrow pointing o
2. Write your name, signature, professional registration number and contact number at the end of the
3. Add the patient's name, date of birth and unique identi
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. Continue the entry from the previous page.
7. At the end of this entry, you need to include all of your details\:
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)
Although this may seem tedious it's actually really important, as it ensures the chronology of your entry is clear to others
reading it later.
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Page 1

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 soon as possible to both reduce the risk of forgetting key details
and 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 three key identi
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 clearly.
5. Complete the entry in the notes.
6. At the end of this entry, you need to include all of your details\:
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)
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