Clinical documentation
Write a record that helps the next clinician understand what happened and what remains to do.
Clinical learning outcomes: Awaiting named clinical review.
What you should learn
- Document assessment and reasoning clearly within local student-recording rules.
- Separate findings, interpretation and plans.
Recognise and explain
- A record needs appropriate identifiers in the clinical system, but personal learning notes must not contain identifiable patient information.
On your placement
Agree the activity and supervision with the clinical team. For patient-facing learning, seek permission and respect the patient’s comfort and care needs.
- Check the local rules for student entries, including dating and timing the entry and identifying yourself as a medical student.
- Draft a history, findings and proposed plan for supervisor review.
- Check that relevant uncertainty, advice, escalation and follow-up are recorded.
- Compare your draft with the final record and discuss what changed.
Start here
GMC: keeping clear clinical records as a student
Read paragraphs 64–69 on clear, accurate records, identifying student entries and handling information safely; then check your placement’s recording rules.
Current guidance
GMC guidance on the quality of clinical placements
Use the placement guidance to agree learning opportunities, supervision and feedback with your team.
Discuss
Starting your emergency medicine placement
Learn how to contribute safely, seek help early and turn ordinary ED work into supervised learning.
On your next shift
Read your next draft as if you were the clinician taking over: is the outstanding task clear?
How this relates to GMC graduate outcomes and the MLA
These are St Emlyn’s learning connections, not a claim that this page covers every national requirement.
Clinical and professional capabilities: Clinical assessment; Communication; Recognising limits and seeking help.
Practical skills: Clinical documentation.
Suggested placement activities informed by the GMC framework. No new procedure-specific supervision level is assigned here.
Explore the student placement programme
Student practice and graduate expectations
About this resource and its review
A St Emlyn’s guide to learning Emergency Medicine during undergraduate placements. It is not an official medical-school or GMC curriculum. Your medical school’s curriculum and assessment requirements take precedence.
National foundations: GMC Outcomes for Graduates, the practical-skills supplement and the MLA content map applying from September 2026.
Framework checked: 8 October 2026. This is a source check, not clinical sign-off.
Clinical learning outcomes: awaiting named clinical review.
The four learning routes are St Emlyn’s groupings. The six interconnected MLA domains remain part of the official content map.