T07 Evidence and reflection record — Worked example
2026 digital edition · Dr Naeem Aziz DGM FRCP · 2 min read
Hypothetical worked example
Read with chapter 11 and 16
Record learning from real work with minimal identifying detail. Keep clinical records in their proper systems; this is a separate educational record.
Identifier and context
CLIN01. Hypothetical account of a change in function during an inpatient rehabilitation episode. No real patient details or treatment advice are included.
Contribution and reasoning
The doctor brought together differing observations from the team, clarified what was uncertain and recognised that a decision lay beyond the agreed scope. Additional advice was sought and responsibility for follow-up was communicated.
What this illustrates
The account can illustrate reasoning, recognition of limits and coordination. It does not show a diagnosis, a treatment outcome or independent competence across an entire specialty.
Verification
A colleague could comment only on what they actually observed or reviewed. In a real record, the doctor's own account should not be presented as independent confirmation. No observer statement is invented here.
Reflection
The useful learning concerns making uncertainty and the follow-up owner explicit. A next review could examine whether this clarity is maintained in other relevant situations. It would be misleading to claim improved patient outcomes without appropriate evidence.
Handling
Only the minimum contextual detail needed for learning belongs in the portfolio. Use the authorised system and appropriate disclosure checks. Preserve the original clinical record; anonymising a reflection does not mean altering clinical documentation.