1. Why the record is part of the treatment

This course

1 hour of verifiable CPD. Standalone. GDC Development Outcomes A and D. Related: Information Governance 1 and 2, Legal and Ethical 1.

Suggested study time

• Purpose of records — 18 min
• What a usable note contains — 20 min
• Corrections, access, screens — 17 min
• Knowledge check — 5 min

Who the record is for

The next clinician at 8am on a Monday. The patient who asks for a copy. You, in two years, when memory has faded. An expert, a GDC caseworker, or a coroner. If the note only makes sense to the person who typed it, it is not a clinical record.

If it is not written, it is hard to prove

That is not a threat. It is how memory works. Advice given, options refused, a delayed radiograph, a telephone conversation about swelling — all of it belongs in the record close to the event.

Everyone who touches the patient writes

Nurses, hygienists, therapists and dentists. Reception notes a change of GP or a fall in the waiting room. Do not leave the dentist to invent a nurse’s observation at 6pm from memory.

Templates

Templates speed charting. They also create identical “soft tissues NAD” on a patient with an ulcer. Edit the template. A copied-forward medical history that nobody rechecked is a clinical risk, not efficiency.