Countersigning a junior colleague's handover note after a fall
You are the senior staff nurse on a 30-bed medical ward and must countersign a handover note written by a newly joined colleague before it goes into the patient's file. The note reads:
“Bed 12 was given the 6 pm antibiotic by the junior nurse late, at 7:10 pm. Patient was having fever since two days, so doctor was not told about the same and he did not visit. Fall was occurred in the bathroom at 6:30 pm while attendant was absent, patient is alright now, no fracture. Sister-in-charge should take strict action against the attendant.”
The patient is a 68-year-old man being treated for pneumonia who had a temperature of 38.9 °C at 4 pm. He fell, did not lose consciousness, and was helped back to bed; a separate observation chart exists. When you raise the problems, the junior nurse is defensive and says the note “means the same thing in fewer words”. One hour remains before the shift ends and the incident form has not yet been completed.
1. Identify four distinct language errors in the note, correct each, and name the rule that is broken.
Read the worked answer
- “was having fever since two days” → “had been febrile for two days” / “had had a fever for two days”. Two rules: the past perfect continuous (or past perfect) is needed for an action continuing up to a past point, and “since” takes a point of time (since Tuesday), “for” takes a duration (for two days).
- “Fall was occurred” → “The patient fell in the bathroom at 18:30.” “Occur” and “fall” are intransitive verbs and cannot be made passive; there is no agent to be acted upon.
- “not told about the same / regarding the same” → “the doctor was not informed”. “The same” used as a pronoun for a previously mentioned fact is a legalistic Indianism that is vague in a clinical record; name the thing (the temperature of 38.9 °C) instead.
- “patient is alright now” → “the patient is currently stable; no external injury or deformity was found on examination”. “Alright” is conversational and non-clinical; a record needs an observable criterion, not a reassurance.
- Also worth flagging: “was given … by the junior nurse late” is an ambiguous word order - better “the 18:00 dose of [drug, dose, route] was administered at 19:10, a delay of 70 minutes”. Exam point: in documentation, vagueness is a clinical risk, not a style choice - “alright” cannot be audited, “stable with normal observations at 19:00” can.
2. What essential information is missing from the note, considering that it may later be read in a legal or disciplinary proceeding?
Read the worked answer
Missing items, grouped:
- The drug: name, dose, route and who prescribed the 18:00 antibiotic. “The antibiotic” is not identifiable after the chart is separated.
- The delay: the reason for the 70-minute delay and who administered the dose.
- Post-fall assessment: vital signs and neurological observations after the fall, level of consciousness, pain score, range of movement, and whether there was any head strike. A fall in a 68-year-old on treatment for pneumonia is a serious event, not a sentence.
- Who examined the patient after the fall, at what time, and what was advised (analgesia, X-ray, observation frequency).
- Escalation trail: the time the doctor was informed, the doctor's name, and the instruction received - this is precisely the gap the note admits and then leaves open.
- Family communication: whether the attendant or relatives were informed, and by whom.
- Formal record: the incident form number and time of filing, plus the time and signature of the person writing the note. Reasoning: a handover note is a contemporaneous record. Anything that cannot be reconstructed from it - who, what, when, why - will be reconstructed by someone else, less sympathetically.
3. Rewrite the last two sentences in an objective professional register and explain why the original wording is unacceptable.
Read the worked answer
Rewritten: “At 18:30 the patient was found on the floor of the bathroom. He had not lost consciousness and was assisted back to bed. Observations at 18:45 were pulse 92/min, BP 128/78 mmHg - within his baseline range - and no external injury or deformity was found. The treating doctor was informed at 18:55 and advised 4-hourly observation and an X-ray of the right hip. The attendant was requested to remain with the patient and the call bell was placed within reach. Incident form no. ___ filed at 19:30.”
Why the original is unacceptable:
- “Patient is alright now” is a conclusion without evidence - it tells the reader nothing about what was assessed or by whom.
- “Sister-in-charge should take strict action against the attendant” is a disciplinary recommendation, not a nursing observation. It assigns blame before any inquiry, invites a dispute, and can be read as prejudicing the very investigation it demands. If attendance is a genuine safety problem, it is escalated separately and factually (“the attendant was not present in the room at the time of the fall”).
- The register is wrong for the purpose: an incident record is written in the passive, factual, third-person style, with times and observations, not in the voice of an aggrieved employee.
- It omits the two facts that matter most legally - when the doctor was informed and what was found on examination - while including an opinion nobody asked for. Exam point: document what you saw and did, not what you feel about the person who was absent.