Lesson 5 - Accurate Clinical Documentation
1. Lesson Overview
Information collected by an assistant practitioner becomes part of the material used by the clinical team. The usefulness of the appointment therefore depends on the quality of the written record.
The practitioner must record what the patient or family actually reported. They should distinguish reported information from their own observations and avoid adding clinical interpretations.
Records should be clear, accurate, relevant and completed promptly. It should always be possible to identify who provided the information and who created the record.
Suggested duration: 60 minutes
Delivery method: Self-directed learning followed by a documentation workshop
Practical requirement: Completion and review of a fictional patient record
2. Learning Outcomes
By the end of this lesson learners should be able to:
Explain why accurate documentation is important.
Record the patient’s or family’s account without changing its meaning.
Identify the source of each important piece of information.
Distinguish reported information from direct observation.
Avoid inappropriate diagnostic or clinical interpretations.
Use clear, respectful and objective language.
Record uncertainty, disagreement and missing information accurately.
Correct an error without concealing the original record.
Complete records promptly and store them in the approved location.
Recognise documentation that requires urgent clinical review.
3. The Lecture
Why documentation matters
The assistant practitioner’s written record may be reviewed by:
The assessing clinician.
Other members of the clinical team.
The patient.
A parent or carer where appropriate.
Another healthcare professional.
An auditor.
The Care Quality Commission.
A safeguarding professional.
A court or other legal body where disclosure is lawfully required.
The person reading the record may not have attended the appointment. The documentation must therefore make sense on its own.
Poor documentation can result in:
Important information being overlooked.
Clinical decisions being based on inaccurate information.
Confusion about who provided an account.
Risk concerns not being followed up.
Repeated questions for the patient or family.
Delays to the assessment.
Confidentiality breaches.
Complaints or disputes.
Difficulty understanding what happened during the appointment.
Accurate documentation protects the patient, practitioner and service.
Core principles
A good record should be:
Accurate: It reflects the information provided.
Clear: Another person can understand it.
Relevant: It focuses on the purpose of the appointment.
Objective: It avoids unsupported judgement.
Attributed: It identifies who provided the information.
Complete: Required sections and significant information are included.
Timely: It is completed as soon as possible.
Secure: It is stored only in an approved system.
Traceable: It identifies the practitioner and date of completion.
Respectful: It describes the person without insulting or stigmatising language.
The UK GDPR accuracy principle requires organisations to take reasonable steps to ensure that personal information is not incorrect or misleading. Records should also make the source and status of information clear. ICO guidance on the accuracy principle
Record what was reported
The practitioner should document the patient’s or family’s account rather than what they think the person meant.
For example a parent may say:
“He becomes very angry when asked to stop playing.”
An accurate record might state:
“His mother reports that he becomes very angry when asked to stop playing.”
The practitioner should not change this to:
“He displays pathological demand avoidance.”
The second version applies a clinical interpretation that the parent did not provide.
Identify the source
The reader must be able to see who provided the information.
Useful phrases include:
“He reports…”
“She describes…”
“They state…”
“His mother reports…”
“Her father recalls…”
“The patient’s teacher questionnaire states…”
“Both parents report…”
“The patient and her mother gave different accounts…”
“This information was taken from the referral form…”
Avoid vague phrases such as:
“It was reported…”
“The family said…”
“Apparently…”
“It is believed…”
“Everyone agrees…”
These phrases may make the source unclear.
Use the correct pronouns and names
The practitioner should confirm:
The patient’s preferred name.
The correct spelling of their name.
Their pronouns.
The name and relationship of each informant.
The record should use this information consistently.
The practitioner should not make assumptions about a person’s relationship, identity or parental role.
Distinguish reported information from observation
Reported information is what somebody tells the practitioner.
Observation is what the practitioner directly sees or hears during the appointment.
Reported information:
“His mother reports that he frequently leaves his seat during lessons.”
Direct observation:
“During the video appointment he stood up and left the camera view on three occasions.”
These statements provide different types of information. They should not be combined in a way that makes the source unclear.
For example the practitioner should not write:
“He is unable to remain seated.”
This statement may sound like a clinical conclusion. It does not explain whether it was reported or observed.
Describe observations objectively
An objective observation describes visible or audible behaviour.
Objective wording:
“She gave brief answers to most questions.”
“He asked for the question to be repeated on four occasions.”
“She became tearful when discussing school.”
“He walked around the room while his father answered questions.”
“She looked towards her mother before answering several questions.”
“He spoke over his mother on several occasions.”
“She requested a five-minute break after approximately 30 minutes.”
Interpretive wording to avoid:
“She had poor communication.”
“He was clearly hyperactive.”
“She appeared manipulative.”
“He lacked empathy.”
“She was attention-seeking.”
“He was deliberately uncooperative.”
“She was obviously depressed.”
The clinical team can interpret observations within the wider assessment.
Use direct quotations selectively
A direct quotation can be useful when the person’s exact wording is important.
This may include:
A risk disclosure.
A description that may otherwise lose meaning.
A statement relevant to consent.
A statement that shows the person’s own perspective.
A disputed or particularly significant comment.
For example:
“He stated ‘I sometimes think everyone would be better off without me.’”
The practitioner should not place quotation marks around words unless they are confident that these were the person’s actual words.
Most of the record can be written as an accurate summary.
Avoid adding a diagnosis
The practitioner should not convert reported behaviour into diagnostic terminology.
Reported account:
“She reports that she worries about making mistakes and checks her work several times.”
Inappropriate interpretation:
“She has obsessive-compulsive disorder.”
Reported account:
“His father reports that he becomes upset when plans change.”
Inappropriate interpretation:
“He has autistic rigidity.”
Reported account:
“She reports hearing her name when nobody appears to be present.”
Inappropriate interpretation:
“She experiences auditory hallucinations.”
The descriptive information should be recorded and passed to the clinician.
Avoid unsupported mental state conclusions
The assistant practitioner may observe behaviour during an appointment. They are not expected to complete an independent mental state examination unless specifically trained and authorised.
They should avoid statements such as:
“No psychosis.”
“No mental health concerns.”
“Insight was poor.”
“Risk was low.”
“Capacity was intact.”
“Mood was clinically depressed.”
“There was no safeguarding concern.”
These require clinical judgement.
They can record:
What the person said.
What was directly observed.
Whether an approved question was answered positively or negatively.
What information was escalated.
Which clinician reviewed the concern.
For example:
“She denied current thoughts of self-harm when asked the question on the approved form. No wider risk assessment was undertaken by the assistant practitioner.”
Use respectful language
The record should describe difficulties without judgement.
Avoid:
“Badly behaved.”
“Lazy.”
“Manipulative.”
“Attention-seeking.”
“Difficult parent.”
“Non-compliant.”
“Normal child.”
“Odd.”
“Strange.”
“Aggressive personality.”
“Poor historian.”
Use specific descriptions:
“His mother reports that he refused to complete the task.”
“She found it difficult to recall dates from early childhood.”
“He raised his voice and struck the table with his hand.”
“She did not attend the previous appointment.”
“He stated that he does not wish to take the medication.”
“The parent gave lengthy answers and required several prompts to return to the question.”
Specific language is clearer and less judgemental.
Separate fact from opinion
A fact can usually be checked. An opinion reflects somebody’s view or interpretation.
Fact:
“The school report records three fixed-term exclusions during Year 8.”
Parent’s opinion:
“His mother feels that the school did not provide enough support.”
Patient’s opinion:
“He feels that the exclusions were unfair.”
All three may be relevant. The record must show which type of information each statement represents.
The practitioner should not present an opinion as an established fact.
Record examples clearly
Examples should include enough detail for the clinician to understand what happened.
Where relevant the practitioner may record:
The situation.
What the person did.
What another person observed.
How often it happened.
How long it lasted.
The impact.
What support was required.
The age or developmental period.
For example:
“His mother reports that he frequently forgets equipment for school. During the previous week he forgot his PE kit twice and left his homework at home on one occasion. She states that she now checks his school bag each evening.”
This is more useful than:
“He is very forgetful.”
Avoid unnecessary detail
The record should be sufficiently detailed without becoming a transcript of the whole conversation.
Include information that:
Answers the form or template.
Clarifies an important example.
Describes relevant impact.
Identifies uncertainty or disagreement.
Relates to risk or safeguarding.
Explains why the appointment was incomplete.
Records an action or escalation.
Avoid:
Repeated versions of the same example.
Unrelated family stories.
Personal opinions about the patient.
Information about other people that is not relevant.
Informal conversation that does not relate to the appointment.
Speculation.
The purpose is an accurate clinical record rather than a word-for-word transcript.
Maintain the structure of the template
The practitioner should record information in the correct section.
For example:
Developmental information belongs in the developmental history section.
Medication information belongs in the medication section.
Risk disclosures belong in the appropriate risk section and may also require a separate escalation record.
Observations should be recorded separately from reported history.
Placing information in the wrong section may make it difficult to find.
If the information relates to more than one section the practitioner should follow the approved template or ask the supervisor where it should be documented.
Record uncertainty honestly
Patients and families may not remember exact details.
Appropriate wording includes:
“She could not recall the exact age.”
“His father believes this began during primary school but was uncertain.”
“The patient was unsure how frequently this occurs.”
“Her mother could not remember whether this occurred before the age of five.”
“No example was recalled.”
“The respondent was uncertain whether the medication was 10mg or 20mg.”
“This requires confirmation from the clinical record.”
Do not guess or make the information appear more certain.
Record differing accounts
Different people may remember the same event differently.
For example:
“She reports that she generally completes homework without difficulty. Her mother reports that she requires repeated reminders and supervision.”
The practitioner should not decide which account is correct.
If people disagree during the appointment the record should remain neutral:
“The patient and her mother gave different accounts of the support required for homework.”
Avoid:
“The patient lacks insight into her difficulties.”
This is a clinical interpretation.
Record when a question was not answered
A question may remain unanswered because:
The person did not know.
They could not remember.
They did not understand.
They did not wish to answer.
There was not enough time.
The appointment was interrupted.
The question was not applicable.
The practitioner paused because of a risk concern.
These should not all be recorded as “not known”.
Examples include:
“He stated that he did not wish to answer.”
“Her mother was unable to recall this information.”
“This section was not completed due to time constraints.”
“The question was not applicable.”
“The form was paused following a risk disclosure and was not resumed.”
“Further clarification from the school is required.”
A blank space can be misunderstood. The reason should be recorded where possible.
Record actions and escalation
If the practitioner takes action it should be documented.
The record should include:
What concern was identified.
What the person said or what was observed.
When the concern arose.
Who was contacted.
When they were contacted.
What information was shared.
What instructions were received.
What action followed.
Whether responsibility was transferred to a clinician.
For example:
“At 14:35 she disclosed current thoughts of self-harm. The routine questionnaire was paused. Dr [name] was contacted by telephone at 14:38 and joined the appointment at 14:42. Clinical responsibility for further assessment was transferred to Dr [name].”
The practitioner should not simply write:
“Doctor informed.”
The reader needs to know which clinician was informed and what happened afterwards.
Record the date and attendees
Every appointment record should identify:
The date.
The appointment type.
Whether it was in person, by video or by telephone.
The patient.
Everyone who attended.
Each person’s relationship to the patient.
The practitioner completing the record.
Any interpreter.
Anyone who joined or left partway through.
The source of the main information.
For example:
“The appointment took place by video on 3 September 2026. Jacob attended with his mother Sarah Cohen. The developmental history was provided mainly by his mother. Jacob contributed information about his current school experience.”
Complete records promptly
The record should usually be completed during the appointment or as soon as possible afterwards.
Prompt documentation reduces the risk of:
Forgetting details.
Confusing one patient with another.
Omitting an action.
Delaying clinical review.
Leaving information in temporary notes.
The practitioner should follow the WMI Psychiatry procedure for the expected completion timeframe.
If completion is delayed the practitioner should notify the supervisor where this may affect patient care.
Temporary notes
The practitioner should record directly within the approved form or system wherever possible.
Temporary notes create risks because they may:
Be lost.
Be seen by an unauthorised person.
Remain outside the clinical record.
Be copied inaccurately.
Contain identifiable information in an insecure location.
The practitioner should not use:
Personal notebooks.
Personal email.
Personal cloud storage.
Unapproved mobile phone applications.
Personal messaging services.
Unapproved artificial intelligence tools.
Loose paper unless this is part of an authorised business continuity process.
If authorised temporary notes are required they must be transferred promptly and disposed of securely according to WMI Psychiatry policy.
Recording during the appointment
Typing while somebody speaks can affect rapport.
The practitioner should explain:
“I will type while we talk so that I can record the information accurately. Please let me know if you would like me to pause or repeat anything.”
The practitioner should continue to listen and should not focus entirely on the screen.
They may pause to check:
“Let me make sure I have recorded that correctly.”
The patient or family should not be expected to speak more slowly than is comfortable simply because the practitioner cannot keep up.
Using abbreviations
Only approved and widely understood abbreviations should be used.
Avoid abbreviations that:
Could have more than one meaning.
Are informal.
Are not used consistently.
May not be understood by the patient.
Make the record difficult to read.
Terms such as “Mum”, “Dad” or “school” may be clear in context. Initials can become confusing when several family members are involved.
When in doubt write the term in full.
Copying and pasting
Copying information from an earlier record can introduce errors.
Risks include:
Carrying forward outdated information.
Recording the wrong medication.
Copying another patient’s details.
Presenting historical information as current.
Repeating an earlier error.
Failing to identify the original source.
The practitioner should only carry information forward where this is part of the approved process. They must check that it remains accurate and clearly identify historical information.
For example:
“The referral form dated 10 August 2026 states that…”
This is clearer than copying the information as though it was reported during the current appointment.
Correcting an error
Clinical records should not be silently changed in a way that hides what was originally documented.
If the practitioner identifies an error they should follow the approved correction procedure.
A correction should usually show:
What information was incorrect.
The correct information.
The date of the correction.
Who made the correction.
The reason where this is not obvious.
Whether the clinical team was informed.
For example:
“Correction added on 4 September 2026: The previous entry recorded Methylphenidate 20mg. The patient reported Methylphenidate 10mg. The original entry was a transcription error. The supervising clinician was informed.”
The practitioner should not delete information merely because the patient later gives a different account. The updated account can be added with a clear date and source.
Late entries
If a relevant detail is remembered or received after the original record was completed it should be added as a late entry.
The late entry should state:
The current date and time.
The date of the original appointment.
The source of the additional information.
Why the information is being added.
Any action taken.
It should not be entered in a way that makes it appear to have been documented at the time of the original appointment.
Patient requests for correction
A patient or family may state that the record is inaccurate.
The practitioner should:
Listen to the concern.
Avoid becoming defensive.
Record the requested correction.
Check whether the issue is a factual error or a difference of opinion.
Inform the appropriate clinician or manager.
Follow the WMI Psychiatry correction process.
Avoid deleting a clinically relevant record without authorisation.
A factual error such as an incorrect address may be corrected through the appropriate process.
A person may disagree with a clinical opinion without the original opinion being factually inaccurate. This type of request should be reviewed by a clinician.
Quality checking before completion
Before saving the final record the practitioner should check:
Is this the correct patient record?
Is the date correct?
Is the appointment type correct?
Is everyone who attended identified?
Is the source of information clear?
Are reported information and observations separated?
Have I added any unsupported interpretation?
Are the examples accurate?
Is uncertainty clearly recorded?
Are differing accounts preserved?
Are unanswered sections explained?
Are risk and safeguarding concerns clearly documented?
Have required actions been completed?
Is the record respectful and understandable?
Have I checked names, dates and medication details?
Has the record been saved in the approved place?
Does a clinician need to review anything urgently?
A final test
Before completing the record the practitioner should ask:
“Could another clinician understand what was reported, who reported it and what action was taken without having attended the appointment?”
If the answer is no the documentation needs further clarification.
4. Clinical Perspective
Clinical pearl: Attribution is essential
“Mother reports” and “the patient reports” can have very different meanings. Always identify the source.
Clinical pearl: Description is safer than interpretation
“He walked around the room on three occasions” provides clear information.
“He was hyperactive” applies a clinical label.
Clinical pearl: Uncertainty improves accuracy
A record that openly states “the exact age was not recalled” is more accurate than a confident but invented answer.
Clinical pearl: Document the transfer of responsibility
When a concern is escalated the record should show who accepted responsibility and what happened next.
Common pitfall: Making the writing sound more clinical
Using diagnostic terminology does not automatically improve a record. It may make the record less accurate if the practitioner has added an interpretation.
Common pitfall: Recording only conclusions
“Sleep poor” gives limited information.
A clearer entry might state:
“She reports taking approximately two hours to fall asleep and waking twice most nights.”
Common pitfall: Copying an earlier note
Previous information may be outdated or incorrect. Historical information must be checked and clearly attributed.
Common pitfall: Leaving blanks
A blank section does not explain whether the information was negative, unknown, declined or not asked.
Common pitfall: Delaying the record
Important detail is easily lost. Documentation should be completed promptly.
When to seek support
The practitioner should seek support if:
They are unsure how to document a disclosure.
The record contains risk or safeguarding information.
A patient requests deletion or correction.
Two accounts differ significantly.
The practitioner has entered information into the wrong patient record.
Confidential information has been stored in an unapproved place.
A record has been sent to the wrong person.
An error may have affected a clinical decision.
The practitioner is unsure whether wording is interpretive.
A late entry is required.
The approved system is unavailable.
5. Case Examples
Case Example 1: Reported information and observation
A mother states that her son cannot sit still. During the appointment he remains seated throughout.
An appropriate record would state:
“His mother reports that he frequently leaves his seat at home and school. During this 45-minute video appointment he remained seated and visible on camera.”
The practitioner should not decide that the mother’s account is incorrect.
Case Example 2: An uncertain developmental date
A father believes his daughter started speaking late but cannot remember her age.
An appropriate record would state:
“Her father recalls that her speech developed later than expected but could not remember the age at which she began using single words or phrases.”
The practitioner should not estimate an age.
Case Example 3: Differing accounts
A young person reports having several friends. Their parent states that they rarely socialise outside school.
An appropriate record would state:
“He reports having several friends at school and online. His mother reports that he rarely meets peers outside school. They gave different views about whether friendships are currently a difficulty.”
Case Example 4: A medication uncertainty
A parent is unsure whether the medication dose is 10mg or 20mg.
The practitioner should record the uncertainty and arrange for the information to be checked. They should not select the dose that appears most likely.
Case Example 5: A risk escalation
A patient discloses current thoughts of suicide. The practitioner contacts the supervising clinician who joins the appointment.
The record should include the patient’s relevant words, the time of escalation, the clinician contacted and the transfer of responsibility.
Case Example 6: A factual correction
The practitioner records that a child attends Year 7. The parent later confirms that the child is in Year 8.
The practitioner should follow the approved correction process. They should not silently overwrite the original entry if this would conceal the error.
6. Summary
Accurate clinical documentation should:
Reflect what was actually reported.
Identify who provided the information.
Separate reported history from observation.
Use objective and respectful language.
Include clear examples.
Preserve uncertainty and disagreement.
Explain unanswered sections.
Avoid unsupported diagnoses or clinical conclusions.
Record risk concerns and actions promptly.
Be completed in the correct patient record.
Be stored only in an approved system.
Be corrected through a transparent process.
Be understandable to somebody who did not attend.
The assistant practitioner should never:
Guess missing information.
Change the meaning of an answer.
Present an opinion as fact.
Add a diagnosis.
Record a formal risk conclusion.
Hide an error.
Use unapproved systems or personal accounts.
Copy information without checking its source and accuracy.
7. Further Reading
WMI Psychiatry Clinical Record-Keeping Policy
WMI Psychiatry Information Governance Policy
WMI Psychiatry Consent and Confidentiality Policy
WMI Psychiatry Risk Assessment and Escalation Procedure
WMI Psychiatry Safeguarding Policy
WMI Psychiatry Data Breach Procedure
WMI Psychiatry Business Continuity Policy
8. Reflective Exercise
The learner should consider:
What is the difference between reported information and observation?
Why is “poor historian” less helpful than a specific description?
How would you document information that a parent cannot remember?
What would you do if you realised that you had entered information into the wrong patient record?
How would you record two conflicting accounts?
Which phrases might accidentally imply a diagnosis?
How would you document a risk concern and transfer of responsibility?
Why can copying and pasting create clinical risk?
How would you respond if a patient disputed part of your record?
What checks should you complete before saving a note?
The learner should discuss their answers with their supervisor.
9. Practical Competency Activity
The learner should receive fictional notes from a structured information-gathering appointment.
The notes should include:
Information from the patient.
Information from a parent.
A direct observation.
An uncertain developmental date.
Differing accounts.
A medication detail requiring confirmation.
An unanswered question.
A risk disclosure.
An action taken by the practitioner.
An example of judgemental wording that needs correction.
The learner should produce a clear clinical record that:
Identifies the patient and appointment.
Lists everyone present.
Attributes information to the correct source.
Separates reported information from observation.
Uses respectful and objective language.
Preserves uncertainty.
Records different accounts.
Avoids clinical interpretation.
Records the risk escalation and outcome.
Identifies information requiring confirmation.
Uses the approved template.
Is completed and stored through the correct process.
The supervisor should compare the record with the original fictional notes and provide feedback on accuracy, clarity, attribution and professional boundaries.
10. Knowledge Check
Complete the short knowledge check below to consolidate your learning and check your understanding of the key principles covered in this lesson. You can review the lesson content again before submitting your answers.
