Recording exact words and safe handover

Clear records and handover let the next clinician judge urgency without asking the patient, parent or carer to repeat everything. In urgent contacts, vague notes can obscure risk; factual records enable safer action.

Notes should state what was said, when it was said, how the contact occurred, where the patient was, what was done, and who took responsibility. The aim is not a long narrative but a reliable account someone else can act on.

What to record

• Exact words: the patient's, parent's, carer's or online request's wording wherever possible.
• Patient details relevant to the route: baby or child's age, pregnancy status, recent pregnancy status or postnatal context where relevant.
• Time and route: phone, desk, online request, message, care-setting contact or third-party call.
• Current location: where the patient is, especially if emergency help may be needed.
• Safe contact details: call-back number and what happened if the line dropped or contact failed.
• Action and ownership: who was alerted, what route was used, and who accepted responsibility for the next step.

Make handover usable

A safe handover is specific. "Parent says 6-week-old baby is floppy, has not fed, no wet nappies since last night, at home, number confirmed, duty clinician interrupted at 10:14" gives clear context and next steps; "baby unwell" does not.

Record refusals, uncertainty, failed call-back, disconnection, online delay or a patient leaving before escalation is complete. These details affect what happens next and must be visible.

Handover detail

If the words sounded urgent when the patient, parent or carer said them, they should still look urgent in the record.