Documentation and Record Keeping
What this domain tests
Documentation stations test whether you can produce a record that another clinician could act on without you: accurate, contemporaneous, attributable, and complete for the encounter. In the OSCE this is often assessed through what you say you will record and how you structure it, or through a written note.
Core rules
- Record contemporaneously or as soon as practicable, with the date and time of the encounter and of the entry.
- Identify who provided the information and who recorded it. Attribute patient statements as patient-reported.
- Include the clinically relevant content: presenting issue, pertinent positives and negatives, assessment, action taken, advice given, and follow-up plan.
- Record every communication with another clinician: who, when, what was agreed, and who authorized any change.
- Record interventions and their outcomes, including counselling delivered and the patient's demonstrated understanding.
- Do not alter a record after the fact without a dated addendum; never delete or overwrite.
- Respect privacy in what you record and who can access it.
Worked example
You triage a patient with suspected shingles and refer them for same-day assessment.
Reasoning: the note should state the date and time, the patient's reported symptoms (unilateral burning pain with a vesicular rash in a dermatomal distribution, onset two days ago), pertinent negatives (no eye involvement reported, no immunocompromise reported), the assessment that same-day medical assessment is warranted, the advice given, the referral made and how, and the follow-up plan. If you spoke with a clinic, record the time, the name and role of the person, and what was arranged. Sign and date the entry.
Traps that cost marks
- Recording conclusions without the supporting findings.
- Omitting the advice given and the patient's response.
- Leaving out the time and identity of a clinician contacted.
- Editing an earlier entry rather than adding a dated addendum.
- Recording more personal detail than the care requires.