How much detail should I include in a patient's records?

To fulfil their primary purpose of supporting patient care, your records should include:

  • relevant clinical findings
  • your differential diagnosis and steps you took to exclude it
  • decisions made
  • information given to patients as part of the consent discussion
  • any drugs or other treatment prescribed
  • the date of each entry
  • the identity of the person making it.

Telephone consultations, handwritten notes, test results and correspondence also form part of a patient's medical record. Complaints correspondence should be filed separately.

Find out more in our guide to effective record-keeping.

This page was correct at publication on 28/01/2022. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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