Planning, Documentation, and Records Management
What you must know
Documentation is the evidentiary trail of professional judgment. Master document control (unique identifiers, revision numbers, approval signatures, distribution lists), as-built and red-line conventions, chain of custody for samples, contemporaneous field notes, and electronic audit trails.
Retention is governed by the longest applicable requirement: statute, regulation, contract, insurer, or litigation hold. A legal hold suspends all routine destruction immediately, including auto-delete and backup rotation. Records containing personal or confidential information require access control, minimum-necessary disclosure, and secure disposal.
Corrections must never obscure the original entry: single line through the error, initial and date, write the correction alongside. For electronic records, use the system's versioning rather than overwriting.
Traps
- Destroying records “on schedule” while a hold or open claim exists.
- Notes written days later and presented as contemporaneous.
- Altering or backdating an entry - this destroys credibility regardless of the underlying facts.
- Assuming email or text messages are not records. They are.
- Releasing records to a third party, including a family member, without authorization or legal process.
Worked example
You discover a transposed measurement in a signed field log. The correct response: strike a single line through the error so it remains legible, write the correct value, initial and date it, and add a brief note of explanation. Do not erase, white out, or reprint the page.
Rule of thumb
“If it is not documented, it did not happen” - and if it is documented badly, it is worse than not documented at all.