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Challenges in governance and patient records (1 CPD hour)

Dr Grant Ingrams addresses some tricky scenarios where the security or accuracy of records could be at risk.

Learning objectives

This module will offer advice on keeping medical records updated and safe:

  • Ensuring that records are clear, accurate, legible and contemporaneous
  • Including recordings of phone consultations and emails in the record
  • Correctly recording symptoms, rather than unconfirmed diagnoses
  • Completing the IG Toolkit
  • complying with the Confidentiality and Disclosure of Information Code of Practice
  • retaining all records indefinitely

This module was first published on 8th June 2011 and was up to date with all key guidelines and evidence at that point. It will be reviewed as part of our routine update cycle by 8th June 2013 but will be updated sooner to reflect any key guideline changes.

Dr Grant Ingrams is a GP in Coventry and immediate past chair of the GPC IT subcommittee.

Article only | Full CPD module