Documentation on-call is not about writing long notes.

It’s about writing clear, defensible, useful notes.

At 3am, nobody needs a novel.

They need to know:

👉 What happened
👉 How sick the patient was
👉 What you did
👉 What the plan is
👉 When to escalate

That’s it.

Good documentation protects patients.

Great documentation protects you.

First mindset shift

Stop thinking:

❌ “I need to write everything”

Start thinking:

✅ “Would another doctor understand exactly what I did?”

Clarity > length

Short and structured beats long and messy every time.

Why documentation matters more on-call

Because:

you often see patients briefly
multiple doctors cross-cover
teams change in the morning
decisions happen quickly
complaints often involve nights/weekends

Morning team relies entirely on your notes.

If your note is unclear, they assume:
👉 nothing was done

Which is frustrating and unsafe.

The golden rule

Every review should answer 5 things:

Why was I called?
How sick was the patient?
What did I find?
What did I do?
What’s the plan?

If these are documented, you’re covered.

A simple safe structure (use every time)

Use this format consistently.

Makes life very easy.

🕒 Time + reason for review

Always start with:

date
time
why called

Example:

02:15 – Asked to review patient for hypotension and NEWS 6

This shows urgency and context immediately.

🩺 A–E assessment

Brief, not essay.

Example:

A: talking
B: RR 24, sats 90% RA
C: BP 85/50, HR 120, CRT 4s
D: alert, glucose 6
E: febrile 38.5

This shows:
👉 you assessed properly

Very important medico-legally.

Even if normal, document briefly.

🧠 Impression

What you think is happening.

Example:

Likely septic shock secondary to pneumonia

Shows clinical reasoning.

💉 Actions taken

Be specific.

Example:

2 IV cannulas
Bloods + cultures
1L IV fluids
IV antibiotics given
Oxygen started

If you don’t write it, legally it didn’t happen.

📋 Plan

Always include clear next steps.

Example:

Repeat obs 30 mins
Recheck BP
Escalate if systolic <90
Registrar informed
Review in 1 hour

This tells nurses and day team exactly what to do.

Prevents repeat bleeps.

That’s it.

That’s enough documentation.

Short. Clear. Safe.

Real NHS example

Bad note

“Reviewed. Unwell. Plan as above.”

Meaningless.

No protection.

Good note

Clear A–E, actions, plan.

Anyone can understand instantly.

Morning team trusts you.

You’re protected.

What you must always document

Never miss these:

✅ time
✅ observations
✅ assessment
✅ treatment given
✅ escalation discussed
✅ clear plan

These are your legal shield.

Common junior mistakes

❌ writing nothing
❌ documenting hours later
❌ vague wording (“stable”)
❌ forgetting obs
❌ not writing escalation
❌ copy-paste notes
❌ huge essays with no structure

Long doesn’t mean safe.

Clear means safe.

Practical on-call tips

Write notes immediately

Don’t say “I’ll write later”

You’ll forget details.

And details matter.

Use bullet points

Faster + clearer

No one wants paragraphs at 3am.

Document escalation

Very important

Write:

Discussed with registrar

Shows shared decision-making.

Huge medico-legal protection.

Document ceilings of care

If DNACPR or ward-based care, always record.

Prevents confusion later.

Keep it readable

Morning team reads 20+ notes.

Help them.

What seniors look for in your notes

Consultants don’t want essays.

They want evidence you:

assessed properly
recognised severity
acted appropriately
escalated when needed
made a safe plan

That’s all.

Senior mindset

Good doctors don’t write more.

They write clearer.

Fast, structured, defensible notes.

It’s a safety skill, not admin work.

Simple documentation template you can memorise

Use this every time:

Time
Reason
A–E
Impression
Actions
Plan
Escalation

If you cover those 7 things, you’re safe.

Take-home concept

Documentation is not paperwork.

It’s communication and protection.

Clear notes:

help the next doctor
reduce mistakes
protect you legally

On-call, write less — but write smart.

If it’s not documented, it didn’t happen.