Recording exact words and safe handover

Clear records and handovers help the next clinician see urgency without making the patient, carer or care worker repeat the story. Vague notes can hide deterioration in contacts that may be sepsis.

The record should state what was said, when it was said, how the contact arrived, where the patient was, what action was taken and who accepted responsibility. The goal is a factual account someone else can act on.

What to record

• Exact words: for example "confused", "very weak", "not passed urine", "floppy", "blue", "mottled", "not themselves" or "something is seriously wrong".
• Infection context: fever, urine infection, chest infection, wound, rash, recent surgery, pregnancy or recent pregnancy when mentioned.
• Time and route: phone, desk, online request, message, care-home contact or third-party call.
• Current location and safe contact details: especially if emergency help may be needed.
• Action taken: who was alerted, what route was used, and what advice or wording was given under local protocol.
• Ownership: the clinician, service, manager or pathway that accepted responsibility for the next step.

Make handover usable

"Urine infection, now confused and very weak, at home with daughter, not passed urine today, duty clinician interrupted at 10:20" is more useful than "UTI query". Keep the warning words visible.

Record refusals, uncertainty, failed call-backs, disconnections or online delays. These affect the next action and must be visible.

Digital/records detail

If the words sounded urgent when they were said, they should still look urgent in the record.