Record keeping

They serve as an important reminder to the clinician who has consulted with the patient, and also provide important information to others sharing that patient’s care. It is important for a record to be adequate and include key points such as history and examination, relevant clinical findings, the decisions made and actions agreed, including the advice or information given. Medical records may also be required for legal purposes and are essential in defending medical negligence claims.

The risk team have identified the following key tools from our resources to help you work through this common area of risk:

• eLearning module: Good practice in record keeping for GPs. This RCGP-accredited module helps GPs build on the requirements associated with good record keeping.
• MDDUS runs various interactive Zoom training events that are based around record keeping with courses suitable for GPs.
• Podcasts: Risk Bites. Listen to our podcast series MDDUS Risk Bites which follows the care of fictitious patient Mrs Roberts across two different practices, as reflected in each practice's clinical notes. This series highlights the importance of adequate medical records when things go wrong, leading to a complaint, a claim of negligence and scrutiny by the GMC.
• Checklist: Clinical record keeping. This practical checklist will help you review your patient record keeping to ensure it complies with GMC guidance.
• eLearning video modules: Roundtable discussion part 1 and part 2. These expert discussions explore the risks associated with dealing with childhood illness in primary care, and are accompanied by reflective guides. The videos can help teams consider how their own systems and records support safe management of patient care.
• Risk alert: Altering clinical records – do’s and don’ts. Clinical records should be made contemporaneously - but there are occasions when it's reasonable to alter an existing record.