Documentation Tips

Overview

In the NHS, your documentation is not admin work — it is part of patient care and part of your professional protection.

Good notes:

  • Improve continuity of care
  • Support clinical decisions
  • Protect you medicolegally
  • Build trust with seniors and MDT

Poor notes cause confusion, risk, and vulnerability.

What Makes Good Documentation?

Good documentation is:

  • Clear
  • Concise
  • Factual
  • Structured
  • Legible
  • Timely

It should allow another doctor to understand exactly what happened without asking you.

The Core Structure of a Ward Entry

Most safe entries include:

  • Date and time
  • Your name and role
  • Reason for review
  • Clinical findings
  • Assessment
  • Plan
  • Escalation (if any)

Example structure:

Reviewed for chest pain. ECG normal sinus rhythm. Troponin pending. Clinically stable. Discussed with registrar Dr X. Plan: repeat troponin, monitor obs, safety net.

Simple. Clear. Defensible.

Always Document Escalation

If you:

  • Spoke to registrar
  • Called consultant
  • Took advice from another specialty
  • Raised concerns about a patient

Document it.

Example:

Discussed with medical registrar (Dr Patel) at 22:10 – agrees with sepsis pathway and will review.

This protects you.

Avoid These Documentation Pitfalls

  • Vague phrases (“patient seems fine”)
  • Emotional language (“patient difficult”)
  • Judgemental comments
  • Copy-paste errors
  • Writing things you did not actually do
  • Backdating entries

If it sounds unprofessional, it will look unprofessional later.

Write as If the Notes Will Be Read in Court

Because sometimes, they are.

This doesn’t mean you should be afraid.
It means you should be:

  • Honest
  • Accurate
  • Objective
  • Professional

You don’t need perfect English. You need clarity.

How to Stay Efficient

Good documentation does not mean long documentation.

Efficiency tips:

  • Use clear headings
  • Avoid unnecessary detail
  • Focus on what matters clinically
  • Develop your own consistent style
  • Learn common phrases used in your trust

With practice, good notes become fast notes.

Common Mistakes for New Doctors

  • Overwriting everything
  • Writing nothing meaningful
  • Forgetting to document senior discussions
  • Not signing entries
  • Leaving plans unclear

These are fixable once you become aware of them.

Reality Check

Everyone writes imperfect notes early on.
What matters is improvement and consistency.

Seniors notice doctors who document well.

Reassurance

You do not need to be an excellent writer.
You need to be a safe, clear communicator on paper.

That skill develops quickly with attention and practice.