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10 tips for quality record keeping

1 Imagine a clinician (or lawyer) reading your notes in 10 years' time, and make sure they make sense.

1 Imagine a clinician (or lawyer) reading your notes in 10 years' time, and make sure they make sense.

2 Include history, examination, treatment, and what you told the patient – in other words, what you have always been taught to include, but is frequently missing.

3 Beware abbreviations unless you are certain they are universally understood.

4 Never include any personal comments that might be misunderstood – imagine the patient reading the record.

5 If you need to annotate or alter a note after saving it, make sure this is clearly marked.

6 Make sure you note what you have told the patient – so that the next doctor to be consulted uses consistent terms.

7 Every consultation needs good notes to be taken – telephone calls especially so.

8 Make the notes as soon as possible after the consultation – if you have jotted down handwritten notes on a complex case, don't wait a long time before entering them on the computer.

9 Always clearly record both consent and your use or offer of a chaperone.

10 Understand the Data Protection Act 1998 – you may be required to explain the notes if the information is not intelligible without explanation.

Professor David Haslam is a PMETB board member and former RCGP chair

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