This document outlines expected standards of documentation for clinicians working in SevernSide IUC and we hope is a useful guide to what we believe good and safe clinical documentation looks like.
It has been created by the Clinical Guardian team, drawing on our experience of auditing cases and subsequent consensus discussions, as well as discussions with member of the senior clinical leadership team.
Why is good documentation important?
- It serves as a record of what happened: actions, steps taken and outcomes
- It informs colleagues who later consult with the patient, supporting continuity of care
- It provides evidence if the standard of your care is ever questioned
What does good (enough) documentation look like?
- Record who you spoke to, and their relationship to the patient if they are a third party.
- Record a level of detail proportionate to the presenting complaint or clinical concern. This usually includes a review of PMH and DH. You will need to record in more detail if the case is borderline, contentious or a safeguarding issue. Have these symptoms occurred before?
- Cover all salient points – records should be defensible and not defensive. Defensible records are clear, concise, factual and accurate: they tell a story.
- Include the patient’s ideas, concerns and expectations of the consultation.
- Document red flag symptoms and signs, including important negatives and any safeguarding concerns
- Check and document allergies
- Include your impression or diagnosis and clinical reasoning to support your decision making and plan. This plan should address both your and the patient’s concerns
- Avoid phrases which imply judgement of the patient e.g. ‘manipulative’, or making comments about colleagues.
- Include specific safety netting.
- Does the patient agree with your plan? If not, say so.
- Read over your notes before closing for accuracy and clarity.
Top tips for efficient and effective consulting
- Avoid prolonged triage consultations if you think the patient needs to be seen face to face. Try to decide this early to allow you to move on to the next case.
- Avoid using templates and copying-pasting notes (from either colleagues or EMIS)
- Avoid using ambiguous abbreviations or personal comments, remembering the patient may be able to access your clinical notes
- Always refer direct referral to speciality rather than to ED/999 where appropriate as this makes a big difference to patient flow in secondary care.
- When you have completed your notes, take a moment to review them. Do you feel comfortable with your clinical documentation?
Further support from the Clinical Guardian Team
- You can meet the Clinical Guardian team here.
- Email us with questions or tricky cases at brisdoc.guardian@nhs.net
- Respond to comments and questions on your cases – we’d love to hear your thoughts!
- Meet us on Teams at the Efficiency Project’s lunch time drop in sessions. These are advertised through the Clinical Newsletter and are open to all clinicians, just show up.
References
- MDU (2025) Effective Record Keeping. Available at themdu.com/guidance-and-advice/guides/effective-record-keeping (Accessed: 17 September 2025).
- GMC (2024) Good Medical Practice. Available at gmc-uk.org/professional-standards/the-professional-standards/good-medical-practice (Accessed: 17 September 2025)