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Clinical Documentation Checklist

Use this checklist to ensure every clinical note you write meets required standards.

Why Checklists Matter

Poor documentation is a leading source of clinical error, medico-legal risk and continuity failure. A consistent documentation standard protects patients and professionals alike.

The Fundamentals

Every clinical entry must be:

  • Dated — always include the full date
  • Timed — 24-hour clock is standard
  • Signed — and printed name with designation
  • Legible — if it cannot be read, it was never written
  • Accurate — reflect what actually happened
  • Contemporaneous — document as close to the time as possible

Never Do This

  • Backdate or falsify entries
  • Use correction fluid — use a single line through errors
  • Leave blank spaces — draw a line through unused space
  • Use unauthorised abbreviations
  • Document on behalf of another clinician without being present
Medico-legal reminder: Clinical records are legal documents. They may be reviewed in complaint investigations, coroner proceedings and litigation. Document as if the record will be examined in court.
Documentation Checklist 
CLINICAL DOCUMENTATION CHECKLIST
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EVERY ENTRY
□ Full date (DD/MM/YYYY)
□ Time (24-hour)
□ Location / ward
□ Your name (printed)
□ Your designation / grade
□ Your GMC/NMC number
□ Signature

CONTENT
□ Presenting complaint / reason for entry
□ Relevant history
□ Examination findings documented
□ Investigations ordered / reviewed
□ Impression / working diagnosis
□ Management plan clearly stated
□ Follow-up plan documented

SPECIFIC CHECKS
□ Allergy status documented
□ Drug history recorded
□ Collateral history source noted
□ Escalation plan documented
□ Patient / family informed of plan

QUALITY
□ Legible handwriting
□ No unexplained abbreviations
□ No blank spaces (draw line through)
□ Errors crossed out (single line)
□ No correction fluid used
□ Contemporaneous (timely)

CONSENT / CAPACITY
□ Consent documented if applicable
□ Capacity assessed if applicable
□ DNACPR status documented if relevant

HANDOVER / DISCHARGE
□ Outstanding tasks listed
□ Pending results flagged
□ Responsible clinician documented