Recording, reporting and preserving facts

Clear, accurate records support candour, complaints processes, safeguarding, data protection and organisational learning. Poor records can obscure risk, confuse timelines and make patients feel the practice is defensive.

What to record

• Date, time and place: when and where the incident, near miss or concern was noticed.
• What happened: factual details, not guesses or blame.
• Who was involved: patient, staff, witnesses and who was informed.
• What was said: key words from the patient or staff, using exact wording where important.
• Immediate action: safety steps, clinical review, manager escalation, contact attempts or practical remedy.
• Follow-up: next contact, agreed actions, complaint route or further review.

Preserving facts

Do not delete, backdate, rewrite or tidy records to make the practice look better. If a correction is needed, follow local procedure so the original timeline remains clear. Preserve relevant order details, call logs, email trails, device information, images, stock records or other evidence.

Maintain confidentiality. Use the approved reporting system and share patient information only with those who need to know.

Links with complaints and data incidents

A single problem may require more than one route. For example, incorrect patient information could trigger candour obligations, a complaint, a data-breach review, record correction and staff training. Do not assume that telling a colleague fulfils formal reporting duties if local policy requires an incident or breach report.

Record facts promptly and honestly. Never rewrite the timeline to hide risk, delay or error.