ABSTRACT
It is important to distinguish between fact, assumption and professional opinion. A fact can best be described as something that is known to have happened or to exist, especially something for which proof exists, or about which there is information. It is extremely important when making entries in the records that assumptions are not made. If assumptions are made there is a real danger that they will be recorded as if they were fact. If the facts and the timings are recorded, then if the patient deteriorates it will be clear from the notes that it is unlikely to be as a result of the alcohol because the symptoms would usually diminish as the effects of the alcohol wear off. But in the absence of facts about how the patient presented it will be impossible to measure if the symptoms have changed and if the patient is deteriorating.
