Source document
A source document is the original record a fact comes from, such as a lab report, an ECG report or a letter. Checking it is how you verify a statement.
Why it matters in a workup
Facts copied between letters drift. A result quoted in a referral may be rounded, out of date or attributed to the wrong test.
When you draft with an AI tool, ask for the source of each statement and check it against the original.
Put it into practice
- Quote facts with their source and date
- Check copied facts against the original
- Keep sources with the patient's workspace
Frequently asked questions
Why not trust the figure in the last letter?
Because letters copy from each other and errors carry forward. The original report is the record.
General guidance on clinical documentation, not advice about any individual patient and not legal advice.
Glossary
Look up related terms
- GroundingGrounding means an AI tool answers from a given set of sources rather than from general training data, and can point to the passage it used.
- HallucinationA hallucination is a statement an AI tool produces that sounds plausible but is not supported by its sources or by fact, such as an invented result.