Exam Pass Notes

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Good Reception Notes

• Write entries that support safe care, continuity, handover and accountability.
• Include enough detail for the next person to understand what happened and what action is required.
• Make the source of each item clear: patient, caller, carer, online request, colleague or another service.
• Do not rely on memory after a busy period or a complex contact; record immediately.

Accuracy and Wording

• Use factual, respectful language.
• Where a patient's exact words affect urgency, safety, safeguarding, confidentiality or complaints, record them verbatim.
• Avoid labels, assumptions, unconfirmed diagnoses, blame and vague shorthand.
• State what is known, what has been reported and what still needs checking.

Actions and Corrections

• Record actions taken, who was informed and who is responsible for the next step.
• Note failed contact attempts, any unsafe contact instructions given and the escalation route used.
• Correct errors promptly using the approved system process.
• Do not edit records to conceal previous entries or actions.

Sensitive Information

• Handle safeguarding, proxy access, safe contact details and third-party information with care.
• Ask for advice before entering details that could create risk if visible online or to a proxy.
• Use approved systems for internal handover of sensitive material.
• Repeated recording problems should be reported so the system can be improved.