Template: Good professional documentation
How to write clearly, factually, and usefully
§What must be included?
- 01What have you observed? (what you saw, heard and measured)
- 02What have you done? (the effort you performed)
- 03How did the citizen react?
- 04Is there anything colleagues should follow up on?
§Separate observation and assessment
Write first what you have actually seen — for example 'the resident ate only half of breakfast and seemed tired'. Then write your professional assessment clearly separated — for example 'assesses that appetite is reduced compared to yesterday'. Then others can form their own opinion on your facts.
§Write so it can be used
- 01Be brief and specific – avoid loose words like 'a bit' and 'maybe'.
- 02Use dates and times where relevant.
- 03Do not use abbreviations colleagues may not know.
- 04Never write in a condescending or disparaging way about the resident.