CONTEMPORANEOUS NOTES
It is very important that you write good notes. They help you process your thoughts and plans, record what you have done and communicate information to your colleagues.
Your notes are legal documents and to be contemporaneous should include:
- Patient: Name and two identifying features (e.g. address, D.O.B, NHS no., unit no etc)
- Time: date and time
- Place: where the clinical encounter occurred
- Person: who was the lead health professional undertaking the clinical encounter
- Scribe: signed, name in capitals, grade, contact details, GMC number
Principles of good documentation
- All clinical encounters should be documented
- Only ever use BLACK ink
- Write legibly
- Entries in the notes should be on official continuation sheets or proformas
- The entry should include all clinical assessments, opinions, plans and conversations
- The person making a clinical decision and the reasons why should be documented
- If using electronic documentation – then only ever use your own login details, and never give your details to another. There is an audit trail of all electronic activity.
ABCDE approach
When documenting your findings and actions for an acutely ill child many clinicians use an ABCDE approach. An example of this is shown here.
