DOCTOR
GMC guidance - https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/protecting-children-and-young-people/keeping-records
Guidance given by the GMC on how to record clinical records:
- Record your work clearly, accurately and legibly
- Documents you make (including clinical records) to formally record your work must be clear, accurate and legible.
- You should make records at the same time as the events you are recording or as soon as possible afterwards.
- You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements.
Clinical records should include:
- relevant clinical findings
- the decisions made and actions agreed, and who is making the decisions and agreeing the actions
- the information given to patients
- any drugs prescribed or other investigation or treatment
- who is making the record and when.
Good Medical Practice, GMC (updated April 2019)