Recording third-party and team information

Reception notes often include information from people other than the patient: relatives, carers, pharmacists, care homes, interpreters, advocates, hospitals, social workers and colleagues. Records should say who provided information and by what route or authority.

Third-party information

You may take information from someone concerned about a patient even if you cannot share patient details back to them. Notes should identify the source and avoid presenting unconfirmed reports as fact.

For example, "daughter reports patient has not eaten for two days and may be confused" is clearer than "patient not eating and confused" if the practice has not yet spoken to the patient.

Team handover notes

• Use approved systems: avoid personal messages for patient details.
• State the owner: name the team, role or person responsible for follow-up.
• Include limits: note if caller authority was not confirmed.
• Keep confidentiality: share only what the recipient needs to act.

When the caller is upset or demanding

Record behaviour factually when it affects safety, confidentiality or process. For example: "Caller shouted, refused identity checks and demanded results." Avoid labels such as "rude daughter".

When information comes from someone else, the record should say who said it and what was done with it.

Need-to-know handover