Record keeping
Write contemporaneous, factual notes of assessment, decisions, consent, treatment, advice and follow-up. Correct errors transparently.
Understand
Contemporaneous notes allow another clinician to understand what happened and why. They protect continuity, safety and accountability more than a template completed without thought.
Assess
Record history, examination, diagnosis or differential, options, consent, treatment details, medicines, advice and follow-up. Date and identify entries and distinguish fact from inference.
Apply
Correct an error transparently without obscuring the original. Record telephone advice, referrals and results, and use a clear mechanism to track outstanding actions.
Key distinctions
Good records separate observed fact, patient report, interpretation and plan. This makes diagnostic uncertainty visible and supports continuity after a handover. Include medicine details, batch numbers or images where required by procedure and policy. Entries should be contemporaneous and corrections traceable; a copy-and-paste note may be lengthy while concealing a changed clinical condition.
Think through a case
A postoperative phone call reports new numbness. The advice and review plan belong in the clinical record, not only in an informal team message.
The distinction to remember
Do not overwrite an erroneous entry silently; retain an auditable correction with time and author.
Test your recall
What makes a clinical note useful later?
Show answer
It shows what was found, agreed, done and planned.