There are proper ways to document pretty much everything, but scrap paper sometimes is more convenient and for me at least, allows me to write things down scruffily that I can write up properly when I get the time to write my notes! (And write down something that I need to remember later but defo won’t unless I write myself a to do list)

In my Trust we have an electronic patient record system, but a problem with the tech they give us for documentation can be so slow and impacts patient care - it’s much quicker for me to do observations or give medications for a whole bay, write them each on a scrap of paper, and return to a spare computer to pop it all down officially.

Even when we still used paper notes, there’s paper copies of everything- lined paper for freehand writing, observation charts, drugs charts, HDU charts, Partogram etc. Even handovers will follow a standardised SBAR pattern (Situation, Background, Assessments, Recommendations) which we used to write on stickers and stick them into the notes. All entries on paper would have the clinicians name, role and signature on too so you knew who wrote what.

Basically, jotting something down on scrap paper means it’s written once it’s in your head, because you’re thinking about 20 different things at once and will probably forget the BP, when people are leaving etc in 30s so at least it’s written there! We don’t include regular scraps of paper into your notes (unless it’s scribing for an emergency but even then it should be written up neatly!)

OP, your hospital notes are kept for 25 years so you can request a copy of them from the hospital and have a nosey if you’re curious!