Document each patient interaction as soon as possible.
It's important to maintain the integrity of the record.
Records can be used as evidence in the event of a complaint or claim.

The purpose of records

In 'Good medical practice' (2024), the GMC says you, "must make sure that formal records of your work (including patients' records) are clear, accurate, contemporaneous and legible".

Good clinical records fulfil several important functions.

They are a reminder of what happened during a consultation, actions, steps taken and outcomes.
They inform colleagues who might subsequently see the patient, supporting continuity of care.
They provide evidence if the standard of your care is ever questioned.

What to include when recording a consultation

In order to best support patient care, your consultation notes should be made as soon as possible.

While taking a proportionate approach to the level of detail, records should usually include the following details:

relevant history and examination findings (both normal and abnormal)
drugs, investigations or treatments proposed, provided or prescribed
the information shared with patients
concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed
information about any reasonable adjustments and communication support preferences
decisions made and agreed actions (including decisions to take no action) and when/where decisions should be reviewed
who is creating the record and when.

Patient records: what else to include

As well as face-to-face consultations, you should record all interactions with patients and any information relevant to their care, including:

notes of phone conversations and home visits
discussions with clinical colleagues and third parties
test results
photographs and X-rays
correspondence (for example, referral letters)
theatre records (if applicable).

The exception to this list is any correspondence relating to patient complaints. This should be kept separately from the clinical record, as it is not directly relevant to the patient's clinical care.

The integrity of records

Make every effort to preserve the integrity of your records so they support patient care and you're not vulnerable to criticism in the event of a complaint or claim.

To help with this, make sure your notes tick the following boxes.

Complete

As described above, ensure your notes are an accurate reflection of what took place during a consultation and that all relevant information is filled with the patient's record.

It's usually not feasible to include each and every detail, but recording significant negatives (as well as positive findings), your differential diagnoses and any steps taken to exclude them, can all be extremely helpful.

Contemporaneous

Write notes as soon as possible while events are still fresh in your mind. Timely record-keeping is important if colleagues need to see the patient again soon afterwards.

Clear and legible

When you need to make a note by hand, take a little extra time and care to write legibly so you and others can read it later.

Entered for the correct patient

Double-check you're saving notes into the correct patient record, especially when they have a common surname or the whole family is on your practice list.

Do not include ambiguous abbreviations

Some abbreviations for conditions and medication are open to misinterpretation and can confuse other members of the healthcare team. Limit them to those approved in your workplace.

Avoid jokey comments

Offensive, personal or humorous comments could undermine your relationship with the patient if they decide to access their records, and can damage your professional credibility if the records are used in evidence as part of a complaint or claim process.

Not tampered with

Never try to insert new notes or delete an entry. In written notes, errors should be scored out with a single line so the original text is still legible and the corrected entry written alongside with the date, time and your signature. If you remember something significant you can make an additional note, but it should be clear when you added the information and why.

Computerised entries will have an audit trail of all entries and deletions, so if something is deleted there should also be a clear record as to why that was done.

Checked

If notes have been dictated and transcribed by a third party, review them for transcription errors and sign entries before they are added to a patient's records.

You should also check, evaluate and initial printed results, reports or letters before they are filed in the patient's records and document any appropriate action.

Effective record-keeping

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