01Principles and purposeThe professional or clinical skill and the decisions it supports.
The record is a clinical communication tool and evidence of how care was reasoned, delivered and followed up. A polished retrospective narrative that hides uncertainty is less safe than a concise contemporaneous entry that distinguishes facts, working judgments and pending information. Proportionate detail means enough for another competent professional to understand the patient’s condition, decisions, ownership and next steps.
GMC standards apply across the UK and require formal records to be clear, accurate, contemporaneous and legible. Data-protection accuracy, access and security duties also apply, while minimum retention periods and disposal rules vary by nation, organisation and record type. England’s Records Management Code of Practice gives guidance for different record types, including retention and disposal; use the code applicable where the record is held.
Key points
- Write the record at the time of the event or as soon as possible afterwards. Identify the author, date and time; label a late entry and explain its source rather than making it appear contemporaneous.
- Record relevant findings, decisions, actions, information shared, patient preferences, consent, who made the decision, who agreed actions and the follow-up or escalation plan, including a decision to take no action.
- Separate observed fact, patient report, collateral account, clinical interpretation and uncertainty. Attribute important third-party information and avoid judgmental language that cannot be clinically justified.
- Correct errors transparently through the approved system. Preserve the original and audit trail, date and sign the amendment, state why it was made and alert relevant teams when the error could affect current care.
- Copy-forward and templates save time but propagate stale diagnoses, examinations, medicines and plans. Verify every imported statement against the current encounter before authenticating the note.
- Patients generally have data-protection access and rectification rights, subject to safeguards. A disagreement with a clinical opinion does not require falsifying history; record the challenge and correct inaccurate facts.
02Situations and prioritiesThe context, relevant information and actions that matter most.
Admission, referral, handover, discharge and results follow-up demand explicit ownership, urgency and contingency plans. A note that lists facts but leaves no responsible person or timeframe creates predictable continuity failure.
When documentation is delayed, preserve the actual event time and the entry time, explain why the note is late and identify the information source. Never backdate or imply observations were made personally when they were reported by others.
A patient may challenge demographic details, history, a diagnosis or an opinion. Correct demonstrably inaccurate facts promptly; where a professional opinion remains defensible, record the challenge, its outcome and relevant context without deleting an authentic record.
Templates, imported problem lists, voice transcription and decision-support output may contain omissions or errors. The authenticating clinician remains responsible for reviewing the final entry and correcting clinically significant mistakes.
03Assessment and interpretationHow to gather information, assess the situation and recognise uncertainty.
Consider the information, its meaning and its limitations before deciding what follows.
- 01
Clinical content check - Why
- Confirm that another clinician can understand what happened and what must happen next.
- Interpretation and limitations
- Look for relevant history, examination, results, assessment, uncertainty, decisions, actions, patient information, safety net, ownership and timing. More text is not safer if crucial actions are buried.
- 02
Provenance check - Why
- Make clear who observed, reported, interpreted and authorised each significant item.
- Interpretation and limitations
- Attribute collateral accounts, remote advice, copied information and trainee-supervisor decisions. Date, time and authenticate entries so later readers can reconstruct sequence and accountability.
- 03
Medication and allergy reconciliation - Why
- Prevent unsafe propagation of incomplete or conflicting high-risk information.
- Interpretation and limitations
- Record source, verification status, reaction detail and unresolved discrepancy. Escalate conflicts affecting immediate treatment instead of copying every list into a single apparently certain version.
- 04
Amendment and access audit - Why
- Check corrections, viewing and disclosure preserve integrity and confidentiality.
- Interpretation and limitations
- Use the approved amendment function, retain the audit trail and reason, and review access only for legitimate care or authorised work. Never inspect a record from curiosity or personal connection.
04Worked approachesCases with ordered reasoning, an action and a check of the outcome.
01Worked caseCorrecting a copied allergy errorA discharge summary incorrectly states “no known allergies” after text was copied forward, although the verified record describes anaphylaxis to an antibiotic and the GP summary has already been sent.+
- 1Verify the reaction from the patient, prescribing record and earlier documentation, distinguishing a confirmed allergy from an unverified label.
- 2Use the electronic record’s amendment process to correct the summary, retaining the original audit trail, author, time and reason for correction.
- 3Assess current harm: check recent prescriptions and contact the receiving GP, pharmacy or patient promptly through an approved route if decisions could be affected.
- 4Final action: issue the corrected discharge communication with explicit high-risk allergy information and document recipients and verbal escalation.
- 5Verification: obtain acknowledgment from the receiving service, reconcile the active allergy field and submit the copy-forward failure for local learning.
02Documentation approachRecording a consent decisionA patient chooses non-operative management after discussing surgery, surveillance and the option to reconsider if symptoms progress.+
- 1Record the patient’s goals, relevant capacity or communication support, options discussed and the benefits, harms and uncertainties material to the choice.
- 2Identify the decision-maker, the decision to take no action now and the clinician’s recommendation without presenting patient agreement as inevitable.
- 3Write the follow-up interval, deterioration triggers, responsible service and how the patient can seek earlier review.
- 4Check the plan is visible in referral and handover documents and that conflicting legacy plans are corrected or clearly superseded.
03Repair approachLate entry after an emergencyA doctor provided urgent treatment and verbal handover but could not complete the full note until later in the shift.+
- 1Enter the note as soon as practicable, clearly labeling it retrospective and recording both the event time and actual entry time.
- 2Describe observations, reasoning, treatment, response and handover from contemporaneous notes and memory, identifying any uncertainty rather than reconstructing false precision.
- 3Name the clinician who received the handover and the outstanding actions, and confirm urgent tasks were not lost during documentation delay.
- 4If the delay exposed a system risk, report it through the appropriate safety route and discuss workflow changes with the supervisor.
05Feedback, follow-up and evidenceReview outcomes, seek feedback and identify what to improve.
- Review documentation quality through targeted audit of high-risk transitions, delayed entries, allergies, result ownership and safety-netting rather than counting note length.
- Close loops on pending results and referrals: record who will review, the expected timeframe, action thresholds, patient notification and what happens if the responsible person is unavailable.
- When a patient requests correction, acknowledge promptly, investigate source and accuracy, correct factual errors and record unresolved disagreement or clinical opinion transparently.
- Use supervised review to compare a note with the actual clinical reasoning and handover, identifying one concrete change that makes future records easier to act upon.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Contemporaneous has meaning
The GMC defines it as recording at the same time as the event or as soon as possible afterwards. An honestly labeled late entry preserves chronology; backdating damages integrity.
Opinion needs attribution
Clinical records may contain justified opinions and differential diagnoses. Clearly identify them as such, include supporting evidence and update their status when later facts change.
Access is purposeful
Technical ability to open a record is not professional authority. Access must be connected to legitimate care or authorised duties and may be audited, including access to colleagues, family or public figures.
Retention is contextual
UK GDPR does not prescribe one universal retention period. Health departments publish schedules by record type and nation; legal holds, inquiries and ongoing care may alter disposal.
07Common pitfallsFrequent interpretation and management errors.
- 01
Backdating a late note, silently changing an earlier entry or deleting an error in a way that removes the original and audit trail.
- 02
Recording “patient informed” without the decision, information, response, responsible clinician, timeframe or contingency needed for continuity.
- 03
Copying forward examination findings, diagnoses or medicine lists without confirming they remain accurate at the current encounter.
- 04
Using insulting, speculative or irrelevant descriptions rather than precise behaviour, attributed reports and clinically relevant interpretation.