Project Logo

Protection of Conscience Project

www.consciencelaws.org

Service, not Servitude
Resources

Notes Illustrated

Consistent Evidentiary Note-making

Sean Murphy*

Related: Making Notes

Starting out
G.K. Chesterfield
341 Napoleon Dr.
Nutting Hill

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.

When you 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.

Structure

23 Sept. 2004

1230- called to OP clinic
1315 - sent to hosp pharm for rx

#####################
24 Sept. 2004

0900
Emerg.- Shadowing Dr. S.


Each day you use the notebook, begin by writing the current date.



Use a clear, standard mark (like cross-hatching) at the end of a day's notes.

Each 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.



If you 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 the note

By doing 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 credibility.

Make entries easy to find

29 Sept. 2004

Re: OP Clinic           
0900 - start
0930 - Pt. DF consent surg
*******************
Re: MAP                
1045 - @ 1030 break @ cafet.
      Conver. with RN Jones
      re: pt. AB
      "What abt the MAP?
      You sd you wdn't
      presc. for AB."



You can use captions to identify different subjects or activities.

 Use some standard mark (like double lines) to divide one captioned section from another.

 

Making corrections

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."
M:"Okay"
S:"Ths came up with pt AB on Sat @ Emerg." OPC"
(Cor. 2004-10-03/0800)

 

 

 

Errors detected while writing an entry should be corrected by striking out the mistake with a single line and writing in the correction.

Errors detected later should be corrected the same way, but write the date and time of the correction next to it

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
M: Yes
_____________
_____________

Re:  Pscyh restraint
________

0925 -  @ rm 403

 

 

If there 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.)"

 

Place the 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.

 

 

Print Friendly and PDF