Recording facts and preserving evidence

Clear records let the practice establish what happened. Vague notes, alterations or missing details make investigation and patient support harder.

What factual recording looks like

Record concrete details: dates and times, who contacted the practice, the caller's exact words where relevant, task status, messages sent, telephone numbers used, who was told and what action followed. Separate opinions or interpretations from observed facts.

If an earlier entry is incorrect or incomplete, do not delete or overwrite it. Follow local procedure to add a dated clarification or correction and keep the audit trail intact.

Record and preserve

• Contact detail: time, route, caller, patient, number or message method.
• Action detail: task, handover, escalation, call-back or advice route.
• Evidence: original message, electronic task, call note, incident report or email.
• Ownership: who accepted the next action and when.

Records support fair review

Accurate records protect patients and staff by showing what information was available and what was done. They help reviewers identify whether a process failed or a person error occurred. Missing detail can lead to unfair conclusions or focus on the wrong part of the workflow.

Capture the sequence

The record should show what was known at each stage, who acted and when the next person became involved. This sequence helps determine whether a handover or the system contributed to the problem.

Do not alter records to make an incident look better; add factual corrections through the proper route.

Digital audit trails