Customer/Patient Notes

Start every note by recording when you wrote it. Use 24-hour format (like 14:30 instead of 2:30 PM) so there is no confusion. This timestamp matters for continuity of care - anyone reading the notes later needs to know exactly when each observation was made.

Clearly identify yourself before writing any notes. Your role matters because a nurse and a doctor might notice different things. Underlining helps anyone scanning the page quickly find who made each entry.

Write what you observed, did, or discussed. Be specific but concise. Stick to facts and avoid opinions unless they are clinical assessments. If someone else reads this six months from now, they should understand exactly what happened.

Finish every entry with your identifying details. This isn't just paperwork - it's accountability. Include your full name, your grade or role (like Medical Student, F2, or Neurology Registrar), your signature, your professional registration number (such as GMC number), and a contact number where you can be reached. This way, if anyone has questions about your notes, they know exactly how to find you.

Take a moment to re-read what you wrote. Would a colleague understand this without asking you questions? Check for any abbreviations that might be unclear. Fix any illegible handwriting if you are on paper. Good notes should not need a decoder ring.

End with any actions that need to happen next. Did you request a test? Refer to a specialist? Flag something for the next shift? Make these clear so nothing falls through the cracks. Your notes are part of a chain - make sure the next person knows what links to their work.