Recording facts, not assumptions

Accurate notes distinguish what was said, what was observed, what was checked and what was done. They should avoid assumptions about motive, diagnosis, blame or character.

Use factual language

Factual language does not need to sound cold. It makes records clearer and safer. For example, "Patient said, 'I have chest pain and feel sweaty'" is more useful than "patient panicking". "Caller shouted and used abusive language after being told the GP was unavailable" is more useful than "caller was horrible".

When you add a concern or interpretation, record the facts that support it. For example, "safeguarding concern raised because patient whispered that partner checks phone and asked not to receive texts" explains why the issue mattered.

Avoid unsafe shorthand

• Do not label: avoid words such as "difficult", "dramatic", "frequent flyer" or "attention seeking".
• Do not diagnose: avoid writing that symptoms are "just anxiety" or "probably viral".
• Do not blame: record behaviour and process facts, not personal judgements.
• Do not tidy away risk: keep urgent or safeguarding wording visible to the right people.

Include source and status

Note who provided the information - the patient, a relative, a carer, an online form, a hospital letter, a pharmacy or another member of staff. If something is unconfirmed, record it as unconfirmed rather than as fact.

Good records make the source of information clear and avoid turning opinion into fact.

Accuracy principle