Why Documentation Is a Core Skill for IMG Doctors?
Clinical documentation in the NHS isn’t just a routine task — it's a legal, professional, and safety-critical responsibility. For IMG (International Medical Graduate) doctors, adapting to UK-style clinical notes can feel overwhelming. Formats like SOAP and SBAR may be unfamiliar, and digital systems used in NHS Trusts can be very different from those abroad.
In 2025, the NHS has ramped up the use of systems like EPIC, SystmOne, and Cerner, with strong expectations for clear, timely, and accurate clinical notes. Whether you're writing ward round updates or escalating a deteriorating patient, your documentation reflects your clinical reasoning and professionalism.
This guide breaks down what every IMG doctor in the UK needs to know about:
The structure and purpose of NHS clinical notes
The use of SOAP and SBAR formats
How to document clearly and legally
The most common pitfalls for IMGs — and how to avoid them
Understanding Types of Clinical Notes in the NHS
When you start working in the NHS, you’ll be expected to write different types of notes throughout your shift, including:
Admission clerking: A full patient history and assessment upon arrival
Ward round notes: Daily updates on inpatient progress
Progress notes: Notes made outside of ward rounds to record changes or reviews
Procedure notes: Documenting actions like cannulation, catheterisation, or NG tube insertion
Discharge summaries: Communicating the outcome and follow-up plans to GPs and patients
Communication notes: Recording phone calls, discussions with relatives, or reviews by other specialties
Each of these notes has its own tone, level of detail, and audience. Some are shared with patients or GPs, while others are for internal use. You are always expected to write objectively, professionally, and in a structured format.
SOAP Format: Writing Notes That Make Sense
The SOAP format is commonly used for progress and review notes across NHS settings.
Subjective (S)
This is the patient’s own account of how they feel. Include any new symptoms, changes since the last review, and relevant complaints. It's also important to note any relevant negatives, such as the absence of pain, fever, or nausea. For example:
"Patient reports feeling more energetic today. No chest pain, fever, or shortness of breath."
Objective (O)
Here, you document measurable clinical findings. This includes:
Vital signs (NEWS2 score)
Physical examination
Fluid balance, input/output
Lab results and imaging summaries
Don’t just list numbers — always interpret the clinical significance where possible. For instance:
"Temp 37.2°C, RR 16, SpO₂ 98% on room air. Chest auscultation: improved air entry bilaterally. CRP reduced from 89 to 60."
Assessment (A)
This section reflects your clinical judgment. Summarise the overall condition of the patient and the direction things are moving. You might include differential diagnoses or highlight concerns. For example:
"Improving clinical picture, likely responding to antibiotics. No features of sepsis. Awaiting OT review before discharge."
Plan (P)
Always conclude with a clear, actionable plan. List specific tasks, investigations, referrals, or follow-up arrangements. Make sure your plan is time-sensitive and realistic:
"Continue IV Co-Amoxiclav (Day 4/5), monitor vitals 6-hourly, discuss discharge in tomorrow's MDT."
Many NHS Trusts expect each note to end with your name, bleep number, date, and time, especially in digital systems that don’t autofill these.
SBAR Format: Communicating and Escalating Safely
The SBAR format is widely used in the NHS for structured communication, especially when handing over patients, referring to other specialties, or escalating to seniors.
Situation (S)
Clearly introduce yourself, where you are, and why you're calling.
"Hello, this is Dr Sharma, FY2 on Ward B3. I’m calling about Mr Green, a 76-year-old with sepsis who is deteriorating despite treatment."
Background (B)
Briefly summarise the patient’s admission, key diagnoses, and recent treatments.
"He was admitted yesterday with suspected urosepsis. On IV Tazocin, had a CT KUB this morning which showed mild hydronephrosis."
Assessment (A)
Describe what you’ve observed and what concerns you.
"He is now hypotensive at 86/55, tachycardic at 115 bpm, and not passing urine. NEWS score is 9. I’m concerned he may be in septic shock."
Recommendation (R)
State what you need clearly — a review, a decision, advice, or an intervention.
"I would like a senior review urgently to consider escalation to HDU and fluid resuscitation."
Using SBAR not only makes communication safer — it also builds your confidence when speaking to senior clinicians, especially in high-pressure scenarios like nights or weekends.
Common Documentation Errors (And How to Avoid Them)
Many IMG doctors make the same documentation mistakes early in their NHS careers. Here’s how to recognise and prevent them:
Writing unstructured narratives
NHS documentation values clarity and brevity. Always use SOAP or bullet points when possible.Forgetting to include senior input
Document who reviewed the patient, what advice was given, and any changes to the plan.Using unapproved abbreviations
Stick to common NHS abbreviations (e.g., IV, PRN, BD) and avoid local shorthand that may not be recognised.Missing time or signature
Every entry should be dated, time-stamped, and signed — even in electronic systems.Leaving out consent for procedures
Always document that consent was obtained verbally or in writing, especially for invasive procedures.
Remember: if it wasn’t written, it didn’t happen — especially in audits, complaints, or legal reviews.
Pro Tips for IMG Doctors in 2025
Save and preview your note before finalising it, especially on EPIC or Cerner, where autosave errors can happen.
Ask colleagues to show you well-written notes — many juniors keep a template library.
Use digital “smart phrases” if available to reduce typing time and maintain consistency.
Join documentation teaching sessions offered during induction or via your Trust’s education centre.
Join the TrewLink Community to Learn More
Still unsure if your notes meet NHS standards? Want to ask other IMG doctors how they structure their SBAR or SOAP entries?
Join our Community Forum where NHS doctors and experienced IMGs share real-world advice, templates, and feedback on everyday clinical challenges like note-taking, handovers, and more.
You don’t have to figure it all out alone — TrewLink is your support system in the NHS.