Healthcare documentation workflow for Tallyfy

Document patient notes with proper accountability

Patient notes that lack structure create continuity of care problems. This Tallyfy template guides staff through proper documentation - timestamp, author identification, observations, and follow-up actions - so anyone reading the notes later understands exactly what happened.

6 steps

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Medical notes

Run this workflow in Tallyfy

Import this template into Tallyfy and run it each time staff need to document patient interactions, assigning the note-taking steps to the responsible clinician

Use Tallyfy's structured steps to enforce 24-hour timestamp format, author name and role identification, observation entry, and professional registration details

Track completed notes through Tallyfy with clarity review prompts before finalization and follow-up actions captured so nothing falls through the cracks between shifts

Import this template into Tallyfy

Process steps

Add the date and time (in 24-hour format) of your entry

5 days from previous step

task

Start every note by recording when you wrote it. Use 24-hour format (like 14:30 instead of 2:30 PM) so there is no confusion. This timestamp matters for continuity of care - anyone reading the notes later needs to know exactly when each observation was made.

Write your name and role as an underlined heading

5 days from previous step

task

Clearly identify yourself before writing any notes. Your role matters because a nurse and a doctor might notice different things. Underlining helps anyone scanning the page quickly find who made each entry.

Make your entry in the notes below this heading

5 days from previous step

task

Write what you observed, did, or discussed. Be specific but concise. Stick to facts and avoid opinions unless they are clinical assessments. If someone else reads this six months from now, they should understand exactly what happened.

What to include at the end of entry

5 days from previous step

task

Finish every entry with your identifying details. This isn't just paperwork - it's accountability. Include your full name, your grade or role (like Medical Student, F2, or Neurology Registrar), your signature, your professional registration number (such as GMC number), and a contact number where you can be reached. This way, if anyone has questions about your notes, they know exactly how to find you.

Review your notes for clarity before moving on

1 day from previous step

task

Take a moment to re-read what you wrote. Would a colleague understand this without asking you questions? Check for any abbreviations that might be unclear. Fix any illegible handwriting if you are on paper. Good notes should not need a decoder ring.

Note any follow-up actions or concerns

1 day from previous step

task

End with any actions that need to happen next. Did you request a test? Refer to a specialist? Flag something for the next shift? Make these clear so nothing falls through the cracks. Your notes are part of a chain - make sure the next person knows what links to their work.