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Record keeping

Failure to keep good and accurate records of treatment and advice to patients will cause considerable difficulties for the Clinician if called upon to justify his or her actions, or to give evidence in legal proceedings. Good record keeping is essential in the context of child protection. It is possible for professional sanctions to be imposed upon the Clinician for poor record keeping.

The GMC "Good Medical Practice" states that a doctor must

"keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed"

The NMC produces a booklet "Guidelines for records and record keeping" (January 2005). A list of publications is produced on the Council's website www.nmc-uk.org. It is stated in the introduction-

"Record keeping is an integral part of nursing, midwifery and specialist community public health nursing practice. It is a tool of professional practice and one that should help the care process. It is not separate form this process and it is not an optional extra to be fitted in if circumstances allow"

The BMA "Access to health records by patients" repeats the GMC Good Medical Practice referred to above, and adds

"Doctors should ensure that their manner of keeping records facilitates access by patients if requested"

www.bma.org.uk

The MDU provides guidance to members as referred to above available at www.the-mdu.com Other sources of guidance include those referred to above from Department of Health Essence of Care, and Royal College of Paediatrics and Child Health.

Records may take several forms

  • Clinical records
  • Client /Patient held records
  • Shared records/integrated records
  • Computer records

This information is for educational purposes only and is not intended to substitute seeking legal or clinical advice where appropriate. For further legal information, please contact the Law Society of England and Wales at www.lawsociety.org.uk.

This guidance is produced by WardHadaway.

© WardHadaway

© NHS Institute for Innovation and Improvement