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1.3 Documentation and clinical records

Post date: 04/07/2017 | Time to read article: 1 mins

The information within this article was correct at the time of publishing. Last updated 19/07/2018

Domain 1: Knowledge, skills and performance
Attribute 1.3: Ensure that all documentation (including clinical records) formally recording your work is clear, accurate and legible

This attribute is about recognising the importance of proper record keeping and following good practice in documenting all contact with patients.

You can demonstrate it by:

  • ensuring that any documentation that records your findings, decisions, information given to patients, drugs prescribed and other information or treatment is up to date and accurate
  • Implementing and complying with systems to protect patient confidentiality.

Medical Protection resources

  • Free CPD-accredited workshop Medical records for general practitioners can help you update your skills in making and keeping high quality medical records.
  • Advice booklet Essential guide to medical records includes guidance on the content and presentation of clinical records and legislation you need be aware of.
  • Online learning system PRISM includes an interactive module exploring the use of medical records in primary care. 
  • Case reports on medical records can help you identify and avoid record keeping mistakes that have caught other medical professionals out.
  • Casebook article ‘What lies beneath’ explains what constitutes a medical record in the event of a complaint or claim.

Read more

<< 1.2 Application of knowledge and experience 2.1 Working with systems  >>

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