IMT - Ethics - Note taking

Question 1

Note taking: How would you approach this scenario? (FY2 clerking lacks detail; supervisor asks to rewrite)

Answer 1

I – Issue
- My documentation is incomplete and may risk patient safety, continuity of care, and medico-legal defensibility.
- Key principle: do not alter the original entry to make it look like it was documented at the time; instead write a new, dated addendum.

S – Seek information
- Clarify with my supervisor what’s missing and what standard/structure they expect (e.g. chest pain clerking).
- Review the record: triage/ambulance notes, nursing notes, ECGs, bloods, observations, meds, previous admissions.
- Re‑see Mr Lewis to confirm the history (pain features, risk factors) and any change since yesterday.

P – Patient safety
- Reassess: current symptoms, observations, ECG/troponin results; check if any red flags were missed.
- If concern for ACS/other urgent pathology: escalate immediately to registrar/consultant and initiate the agreed pathway.

I – Initiative
- Write a new entry: clearly titled “Addendum / retrospective entry”, with date/time now and reference to time of original assessment.
- Use a structured format (e.g. HPC → RF/PMH → Exam/Obs → Ix → Impression → Plan).
- Document any senior discussion, working diagnosis/differentials, and clear plan + safety‑net.

E – Escalate
- Inform the consultant/registrar if the revised assessment changes risk (e.g. new red flags, missed results).
- If this is a recurrent issue: request support (template, feedback, supervised review).

S – Support
- Accept feedback professionally; ask for specific tips and, if available, a ward proforma for chest pain clerkings.

R – Reflect
- Reflect in e‑portfolio with a concrete action plan (templates, time‑stamped addenda, prompt checklist, mini‑audit).

Question 2

What necessary information would you add to Mr Lewis’s notes?

Answer 2

• Patient identifiers + date/time + your name/grade/GMC number.
• History of presenting complaint (structured): onset, character, location/radiation, duration, severity, triggers/relief, associated symptoms (SOB, diaphoresis, nausea, palpitations, syncope).
• Key negatives / red flags (e.g. exertional nature, pleuritic pain, tearing pain, collapse).
• Cardiovascular risk factors: smoking, HTN, DM, dyslipidaemia, FHx, prior IHD/stroke, CKD.
• PMH, meds, allergies, anticoag/antiplatelets, relevant social history.
• Examination + observations (incl. cardio/resp) and any abnormal findings.
• Investigations with time stamps: ECG findings, troponins, bloods, CXR (if done).
• Impression / differentials (e.g. ACS, PE, MSK, GORD, aortic pathology) aligned to findings.
• Plan: monitoring, repeat ECG/troponin timings, analgesia, referrals, escalation criteria; and senior review documented.
• Any discussion with patient/relative (if relevant) and safety‑netting advice.

Question 3

How would you ensure you have the correct patient identifiers on your continuation sheet before making an entry?

Answer 3

• Use a printed label where possible with ≥3 identifiers: name, DOB, hospital/NHS number (plus ward).
• If no label: handwrite the same identifiers at the top of every loose page.
• Cross‑check against the wristband and the electronic record before writing.
• Ensure each page is securely filed in the correct set of notes.

Question 4

If you’re called away by a deteriorating patient and need to finish your documentation later, how would you handle that?

Answer 4

• Prioritise the emergency and hand over/attend immediately (patient safety first).
• If possible, leave a brief time‑stamped holding note: “Seen at [time]; urgent call away; will complete full entry ASAP.”
• Return as soon as feasible and write a retrospective addendum with date/time now, stating it relates to assessment at [time].
• Be factual, avoid speculation, and do not alter the original entry.
• End with signature, name/grade, GMC number, and clear plan/escalation.

Question 5

What are the risks of overusing abbreviations in your notes, and how do you decide what is acceptable?

Answer 5

• Risk: ambiguity → misinterpretation, medication errors, delays, unsafe handover.
• Use only widely recognised abbreviations (preferably per local policy); avoid niche/specialty shorthand.
• For safety‑critical items (diagnoses, procedures, drugs, units): write in full if any doubt.
• Avoid unsafe abbreviations (e.g. unclear dose/units); prioritise clarity over speed.

Question 6

What are the potential consequences of poor note-taking for patient care and your professional practice?

Answer 6

• Patient care: missed information, duplicated work, delayed diagnosis/treatment, poor handover → potential harm.
• Team functioning: uncertainty about decisions/plan; increased workload and conflict.
• Medico‑legal: weak audit trail; harder to justify decisions in complaints, inquests, litigation.
• Professional: undermines trust; may trigger supervisory concern, remediation, or escalation if persistent.

Question 7

Describe how you would reflect on your note-taking practice in your e-portfolio.

Answer 7

• Brief case summary: what happened, what was missing, and the impact/risk.
• Reflection: what I learned about structure, time‑stamping, and addenda vs rewriting.
• Action plan (SMART):
  
  • Use a chest pain clerking template (prompt list) for every similar case.
  • Aim for contemporaneous notes; if delayed, document as retrospective with times.
  • Ask supervisor to review 3–5 clerkings for feedback over the next month.
  • Optional: mini‑audit of my next 10 clerkings against a checklist.
• Re‑review progress at 4–8 weeks and document improvement.