Notes Illustrated

Consistent Evidentiary Note-making

Sean Murphy*

Starting out

Full Text

G.K. Chesterfield
341 Napoleon Dr.
Nutting Hill

23 Sept 2004- 21 Dec.2004

On the face of the notebook write your name, some contact information.

Write the date of the first entry.

When you reach the end of the notebook, add the date of the last entry.

This will allow you to keep a series of notebooks in order.

All entries should be in pen.

Structure

23 Sept. 2004
1230 called to OP clinic
1315 sent to hosp pharm for rx

#####################

24 Sept. 2004
0900
Emerg.- Shadowing Dr. S.

Each day you use the notebook, begin by writing the current date.

Consistently use a clear, standard mark (like cross-hatching) at the end of a day's notes.

Each entry during the day must begin with the time you made the entry. This entry was made at 0900.

Alternative structure with margin

       23 Sept. 2004
1230 called to OP clinic

1315 to hosp pharm for rx
#######################

        24 Sept. 2004
0900 Emerg.
     -Shadowing Dr. S.

The time may be marked as a sub-heading (example above) or in the margin, depending upon the design of the notebook and your preference.

A margin is desirable because it improves readability. You can add a margin to a notebook that does not have one.

Retrospective recording of an incident

25 Sept. 2004
0900- OP clinic

1030 -@1000 pt AB, 16 yrs.
unp int with bf 8-10 hrs prev.

If you are making a note about something that happened earlier, or if continuing notemaking that was interrupted

- begin with the present (entry) time
- include the time of the incident in the body of the note.

By doing this you will always be able to distinguish the time of the entry from the time of the incident. Here the note made at 10:30 refers to an incident that happened at 10:00.

Do not back-date or back-time entries even with an innocent intention. Six months later you will not remember whether the entry was made at the time noted, or later. This will undermine the reliability of your notes and your credibility.

Make entries easy to find

29 Sept. 2004
Re: OP Clinic
0900 - start
0930 - Pt. DF consent surg
*******************
Re: MAP
1045 - @ 1030 break @ cafet.
Conver. with RN Jones
re: pt. AB

You can use captions to identify different subjects or activities.

Consistently use some standard mark (like double lines) to divide one captioned section from another of the same date.

Identify verbatim statements

29 Sept. 2004
*******************
Re: MAP
1045 - @ 1030 break @ cafet.
Conver. with RN Jones
re: pt. AB
"What's your problem with the Mg Af Pl?"
Was on the ward. Heard you wdn't presc. for AB.
"You shouldn't be working in health care" (WTE)

Consistently identify verbatim statements by using quotation marks. Reserve quotation marks for this purpose.

If a statement is almost verbatim but some words may be uncertain, you can use quotation marks qualified by "WTE" - meaning, "Those words or words to that effect."

Making corrections

2 Oct. 2004
Re: Dr. Smith - Ethics
0915 - @0830 met Dr. S @ his off. Clsd dr mtg.
S: "I wnt to talk to you abt inf con. I'm nt sure & pt aut. I'm nt sure you under some issues."
M:"Okay"
S:"Ths came up with pt AB on Sat @ Emerg." OPC"
(Cor. 2004-10-03/0800)

Errors detected while writing an entry should be corrected by striking out the mistake with a single line and writing in the correction.

Errors detected later should be corrected the same way, but write the date and time of the correction next to it.

Do not use white-out, correcting tape or erasers, and do not blot out or scribble over mistakes.

When there is not enough room for correction . . .

M: "The 16 yr old"
S: "Ys. Pt. has the rt to make dec abt treat. To make dec, she mst hv comp inf abt altern avail. Do you agree?"(1)
M: "Yes"
__________
__________
Re: Pscyh restraint
________
0925 - @ rm 403

If there is no room for the correction and/or the date and time, or if you need to correct an omission, use an end note.

Here, retrospective note-making was interrupted by an urgent call for assistance and further note-making about unrelated matters.

An omission was discovered later when retrospective note-making was continued, beginning with a review of the first entry. The omission was marked with an end note.

. . .use an end note.

(1). 2004-10-02, 1600
S: "Ys. RN tol me abt it. Pt hs the rt. (etc.)

Place the end note with the correction in a later notebook entry, or on the back page of your notebook.

If you add end notes to the back page, work from the back of the notebook to the front when adding subsequent notes.

Be consistent

There are suggestions. You may adopt other methods for structuring your notes, identifying verbatim statements or making corrections. You should strive for consistency to ensure that your notes are reliable and will withstand critical scrutiny.