Consistent Evidentiary Note-making
341 Napoleon Dr.
23 Sept 2004- 21 Dec.2004
On the face of the notebook write your
name, some contact information and
the date of the first entry.
reach the end of the notebook, add the date of the last entry.
This will allow you to keep a series of notebooks in order.
All entries must be in pen.
23 Sept. 2004
1230- called to OP clinic
1315 - sent to hosp pharm for rx
24 Sept. 2004
Emerg.- Shadowing Dr. S.
you use the notebook, begin by writing the current date.
clear, standard mark (like cross-hatching) at the end of a
entry during the day must begin with the time you made the entry.
This entry was made at 0900.
The time may be marked in
the margin or as a sub-heading, depending upon the design of the
notebook and your preference.
Retrospective recording of an incident
25 Sept. 2004
0900- OP clinic
1030 -@1015 pt AB, 16 yrs.
unp int with bf
8-10 hrs prev.
are making a note about something that happened earlier
- begin with the present (entry) time
- include the time of the incident in the body of
this you will always be able to distinguish the time of the entry from
the time of the incident.
Do not back-date or back-time entries even with an innocent intention. Six months later
you will not remember whether the entry was made at the time noted, or
later. This will undermine the reliability of your notes and your
Make entries easy to find
29 Sept. 2004
Re: OP Clinic
0900 - start
0930 - Pt. DF consent surg
1045 - @ 1030 break @ cafet.
Conver. with RN Jones
re: pt. AB
"What abt the MAP?
You sd you wdn't
presc. for AB."
use captions to identify different subjects or activities.
standard mark (like double lines) to divide one captioned section from
2 Oct. 2004
Re: Dr. Smith - Ethics
0915 - @0830 met Dr. S @ his
off. Clsd dr mtg.
S: "I wnt to talk to you abt inf con.
I'm nt sure & pt aut.
I'm nt sure you under some issues."
S:"Ths came up with pt AB on Sat @
detected while writing an entry should be corrected by
striking out the mistake with a single line and writing in the
detected later should be corrected the same way, but write the date and time of the correction next to
Do not use white-out,
correcting tape or erasers, and do not blot out the mistakes.
When there is not enough room for correction . . .
M: "The 16 yr old"
S: "Ys. Pt. has the rt to make dec abt treat. To make dec, she mst
hv comp inf abt altern avail. Do you agree?"1
0925 - @ rm 403
is no room for the correction and/or the date and time, or if you need
to correct an omission, use an end note.
Here, the interview was interrupted by an urgent
call for assistance.
. . .use an end note.
1. 2004-10-02, 1600
S: "Ys. RN tol me abt it. Pt hs the rt. (etc.)"
date and time of the correction and the correction in the end note on
the back page of your book. Add end notes as required, working
from the back of the notebook to the front.