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Golden rules of record keeping

Medical defence adviser Dr Jacqui Phillips gives her golden rules for record-keeping in practices

With the number of patients seen every day in general practice, no one can be expected to remember every consultation, which is why record-keeping is such an important ethical requirement for doctors and nurses alike.

Clear, accurate and legible patient records are essential to support patient care and may also become important if there is a complaint or claim, which will typically be made months or years after a consultation. Here are my golden rules:

1. Make an accurate record of relevant clinical findings. Include what you found; what you looked for but did not find; the information given to patients; and any drugs or other treatment prescribed.

2. Your notes should be made at the time of consultation or as soon as possible afterwards e.g. details of home visits.

3. Do not alter an entry or disguise an addition. If the notes are factually incorrect then the amendment must make this clear.

4. Avoid unnecessary comments. Patients have a right to access their records and a flippant remark might be difficult to explain.

5. Take care when dictating notes. Transcribe them as soon as possible after the consultation. Letters typed up by a secretary should be checked, corrected and signed by the doctor concerned.

6. Store records securely and protect electronic data. Have an information security policy in place and ensure all staff are aware of it.

7. Keep records for as long as possible and at least for the minimum retention period defined by national guidance such as Records Management: NHS Code of Practice, available on the Department of Health website.

8. Destruction of records must be complete and secure. Practices are advised to shred paper records. Destroying computerised records may require specialist IT advice.

Dr Jacqui Phillips is a medicolegal adviser at the Medical Defence Union

Golden rules of record keeping