#Documentaion sample page for hospital how to
#Documentaion sample page for hospital registration

What if you are too busy dealing with sick patients to write in the notes at the time? At the end of this entry, you need to include all of your details:Īlthough this may seem tedious it’s actually really important, as it ensures the chronology of your entry is clear to others reading it later. Continue the entry from the previous page.ħ.

Write your name and role, followed by the word “continued” as an underlined heading.Ħ. Write the date and time of the entry on the second page.ĥ. Add the patient’s name, date of birth and unique identifier to the new page.Ĥ.

#Documentaion sample page for hospital registration

Write your name, signature, professional registration number and contact number at the end of the first page.ģ. Write “continued on the next page” or “continued” with an arrow pointing off the page after the entry on the first page.Ģ. If your entry in the notes happens to span more than one page:ġ. Other things to be aware of… What if your entry spans more than one page? Your professional registration number (e.g.At the end of your entry to need to include the following: Make your entry in the notes below this heading (see our other documentation guides).Ĥ. Write your name and role as an underlined heading.ģ. Add the date and time (in 24-hour format) of your entry.Ģ.

#Documentaion sample page for hospital how to

How to make an entry in a patient’s notesġ.

You should indicate the patient’s current location on the continuation sheet:Īt this point, you should already be holding a pen with black ink and you should have ensured the continuation sheet has at least three key patient identifiers at the top. If a patient label containing at least three identifiers is available, then this can be used instead of writing out the information manually. Patient detailsįor every new sheet of paper your first task should be to document at least three key identifiers for the relevant patient: You need to use a pen with black ink, as this is the most legible if notes are photocopied. Ok, so a blank continuation sheet has been thrust towards you and you’ve been asked to document something – let’s remind ourselves of the basics of documentation. You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.