1.3 Documentation and clinical records
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 in general practice 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.
Practical tips to help you plan and prepare for revalidation
Go to guidance