- 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:
- a reminder of what happened during a consultation, actions, steps taken and outcomes
- informing colleagues who may see the patient subsequently and supporting continuity of care
- providing evidence if the standard of your care is ever questioned.
Recording a consultation
In order to best support patient care, your consultation notes should be made as soon as possible and, 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, eg referral letters
- theatre records (if applicable)
- the exception is complaints correspondence, which should be kept separately from the clinical record; 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 is 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 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.
Don't 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 damage your professional credibility if the records are used in evidence.
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.
This page was correct at publication on 30/01/2024. 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.