3. Corrections, access and the screen behind you

Contemporaneous

Write as soon as you reasonably can. If you add later, say so: date, time, that it is a later addendum, and why. Do not backdate. Do not overwrite a previous entry to make the story tidier.

Corrections

Use the audit trail. Strike through meaning with a single line in paper notes so the original remains readable; in software, use the correction function. Never delete a clinical fact because it is embarrassing.

Who may look

Need to know. Not curiosity about a neighbour. Not a screenshot to a group chat. Information Governance 1 covers lawful access in more depth. Lock the screen when you walk away. Angle monitors away from the waiting room.

Subject access

Patients can ask for their records. Do not hide, delay out of spite, or “tidy” the notes when a request arrives. Follow the practice procedure and current UK data-protection timescales. If you are unsure, the IG lead, not improvisation.

Sharing with others

Referrals need enough information to be safe. Copying a whole record into an unencrypted personal email is not helpfulness. Use the agreed pathway.

Always follow current GDC Standards on records and your written confidentiality procedure.