Effective record keeping

Clear, accurate records support clinical decision-making and patient care.

  • 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, the GMC says you 'must record your work clearly, accurately and legibly.' Clinical records fulfil several important functions.

  • A reminder of what happened during a consultation, actions, steps taken and outcomes. No-one's memory is infallible.
  • 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 include the following details:

  • relevant history and examination findings (both normal and abnormal)
  • your differential diagnosis and any steps taken to exclude it
  • decisions made and agreed actions
  • information given to patients, including the different treatment options and risks explained during the consent discussion
  • the patient's concerns, preferences and expressed wishes (this will also be valuable should they lose capacity)
  • drugs or other treatment prescribed and advice given
  • investigations or referrals made
  • the date and time of each entry and your identity.

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 telephone conversations and home visits
  • discussions with clinical colleagues and third parties
  • test results
  • photographs and X-rays
  • correspondence, eg referral letters. 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
  • theatre records (if applicable).

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 are:

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.

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 that you are 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 26/06/2020. 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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