Synopsis
Create clear, accurate, contemporaneous records that support safe continuity, show professional reasoning and preserve an auditable account when information is corrected, disputed, copied, handed over or disclosed.
- Write the record at the time of the event or as soon as possible afterwards. Identify the author, date and time; label a late entry and explain its source rather than making it appear contemporaneous.
- Record relevant findings, decisions, actions, information shared, patient preferences, consent, who made the decision, who agreed actions and the follow-up or escalation plan, including a decision to take no action.
- Separate observed fact, patient report, collateral account, clinical interpretation and uncertainty. Attribute important third-party information and avoid judgmental language that cannot be clinically justified.
Reasoning priorities
Confirm that another clinician can understand what happened and what must happen next.
Look for relevant history, examination, results, assessment, uncertainty, decisions, actions, patient information, safety net, ownership and timing. More text is not safer if crucial actions are buried.
Worked reasoning
A discharge summary incorrectly states “no known allergies” after text was copied forward, although the verified record describes anaphylaxis to an antibiotic and the GP summary has already been sent.
- Verify the reaction from the patient, prescribing record and earlier documentation, distinguishing a confirmed allergy from an unverified label.
- Use the electronic record’s amendment process to correct the summary, retaining the original audit trail, author, time and reason for correction.
- Assess current harm: check recent prescriptions and contact the receiving GP, pharmacy or patient promptly through an approved route if decisions could be affected.
- Final action: issue the corrected discharge communication with explicit high-risk allergy information and document recipients and verbal escalation.
- Verification: obtain acknowledgment from the receiving service, reconcile the active allergy field and submit the copy-forward failure for local learning.