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.