They should be dated and detailed, and made at the time of the consultation or as soon as possible afterwards.
All your records need to be clear, accurate and legible.If you don’t have the evidence to show what’s happened with a patient, it is more difficult to protect and defend your professional position if a complaint or claim arises.Īt every step of your career, it’s crucial that you record your conversations with patients and colleagues, the diagnosis you make, all treatment plans you decide upon, and any post-operative care and communication that takes places. Record keeping is a topic we talk about a lot. Records include electronic documents, hand-written notes, voice recordings, emails, consent forms, text messages, laboratory results, photographs, videos and printouts. Medical records are a key part of a doctor’s responsibilities when it comes to providing good patient care.
