Honesty in Clinical Practice

Clinical honesty means recording accurate findings, writing faithful notes, and explaining reasoning clearly. It also means admitting limits and seeking help, rather than hiding uncertainty. ^[2][1]

Consultations, consent, and clear explanations

Clinicians should describe benefits, risks, and reasonable alternatives without exaggeration. ^[5] Teams must avoid over-promising on vision, comfort, or timelines. ^[1] When time is short, priority should be given to what is clinically essential, with the rest booked promptly and the reasoning documented. ^[5][2]

Records, additions, and audit trails

Notes should be written at the time whenever possible. Late entries must be added as dated addenda with author and reason. Negative findings that influenced decisions should be recorded. Device outputs must be saved or referenced directly, not paraphrased. ^[2][3][4]

• Good practice: use standard forms or clear formats for history, findings and plan; include the referral criteria used; log phone advice with ID checks; and make clear what is fact and what is opinion. ^[3][2]
• Checks that help: use a second clinician to review high-risk referrals; add end-of-day prompts for unsigned records; and review a sample of notes weekly for clarity and completeness. ^[2][3]

Managing uncertainty and escalation

Follow-up advice should explain what symptoms to look out for, when to return, and who to contact if things get worse.

^[6]

Saying, "I’m not certain—here is how we’ll check" is better than masking doubt. Advice from another clinician should be sought through approved systems, with names and times recorded. ^[6][2][3]

Work done under supervision should not be presented as independent. When colleagues or guidelines are used, this must be noted so assumptions can be checked later. ^[1][2]

• Essential details for defensible notes: presenting problem and patient priorities; key findings; decision and alternatives; follow-up advice; and who will do what, by when, with review date. ^[2][3]

References (numbered in text) Why we include references

1. 16. Be honest and trustworthy — Standards of practice for optometrists and dispensing opticians. General Optical Council Find (opens in a new tab)
2. Good medical practice. General Medical Council (2024) Find (opens in a new tab)
3. Patient records — College of Optometrists Find (opens in a new tab)
4. Records Management Code of Practice for Health and Social Care. NHS Transformation Directorate / NHSX Find (opens in a new tab)
5. Shared decision making. NICE guideline NG197. National Institute for Health and Care Excellence (2021) Find (opens in a new tab)
6. Safety netting for primary care: evidence from a literature review. Daniel Jones; Laurie Dunn; Ian Watt; Una Macleod. British Journal of General Practice (2019) Find (opens in a new tab)