Write It As You Do It

Part of Research Assistant (ASSIST) Training: Writing It Down So It Can Be Relied On.

About 1 minutes. Free, in your language, no account needed.

Contemporaneous means now

Records are made at the time the thing happens, by the person who did it. Not at the end of the clinic. Not from memory on the bus home.

Memory is confident and wrong. You will be certain the blood pressure was 128 over 76 and it was 132 over 78, and nothing in the record will reveal the difference.

What a good entry contains

What was done, when, to whom, by whom. A time that is the actual clock time. A signature or initials that identify a real person.

If you write something, sign it. An unsigned entry belongs to nobody, and a record nobody can be attributed to is close to useless.

Never erase

If you make a mistake, put a single line through it so the original is still readable, write the correction next to it, and initial and date the change.

Do not scribble it out, do not use correction fluid, and do not overwrite. The point is that anyone reading later can see what was there first and who changed it. A record with something hidden under a blot invites the question of what was being hidden.

Blank is not the same as zero

If a measurement was not taken, write that it was not taken and why. An empty box is ambiguous forever: nobody can tell whether the value was zero, the test was not done, or someone forgot.

"Not done — participant declined" is a complete record. An empty space is a question no one can answer later.