Recording exact words and safe handover

Clear records and concise handover let the next clinician see what has changed without the patient repeating their history. In contacts about deterioration, vague notes can hide urgency and delay action.

The record should show what was said, how that differs from the patient's usual state, when the change began, how the contact arrived, where the patient was, what was done, and who took responsibility for the next step.

What to record

• Exact words: record the patient's, caller's or carer's phrasing wherever possible.
• Change over time: note what is worse, what is new, and what the person could do before but cannot do now.
• Time and route: state whether the contact was by phone, at the desk, via online request, message, care-home contact or third party.
• Current location: record where the patient is, especially if emergency help may be needed.
• Safe contact details: include a call-back number and what happened if the line dropped or contact failed.
• Action and ownership: record who was alerted, how they were contacted, and who accepted responsibility for the next step.

Make handover usable

A safe handover is specific. For example: "Daughter says father was walking yesterday; now too weak to get out of bed; at home alone; number confirmed; duty clinician interrupted at 10:14" is far more useful than "weakness query".

Record refusals, uncertainty, failed call-backs, disconnections, online delays or a patient leaving before escalation is complete. These details affect what happens next and must be visible in the record.

Handover detail

If the story is about deterioration, the record should show what has changed and who owns the next step.