2. Keeping records and keeping your colleagues informed

In providing care, you must
• keep clear, accurate, and contemporaneous patient records which report
the relevant clinical findings, the decisions made, the information given to
patients and any drugs or other treatment prescribed;
• keep colleagues well informed when sharing the care of patients;
GMC Good Medical Practice, paragraphs 3.4, 3.5

Keeping good records of the clinical encounter enables you or other doctors
to remember and/or understand the care that the patient has been given, and
provides the basis for future care. They are the main way to share information
with other members of the practice team who may be providing care for a
patient. They are also documents which may be needed for legal purposes.
Medical records include both written ones and ones held on computer. Your
paper records should be legible and entered sequentially, with hospital
reports, laboratory reports and x-ray reports filed in date order. Records of
consultations should include the presenting problems, results of examinations
or investigations undertaken, and an indication of the management plan. The
records of patients on long-term therapy should include a clear summary of
medication. Important information in records should be easily accessible; for
example, as part of a summary.

Records should contain factual information and opinions which have some
bearing on diagnosis or treatment. You should remember that patients are
entitled to read their records. They may also legitimately ask that you do not
record some things that they tell you.
Members of your practice team need information about patients in order to
provide care for them. However, patients may sometimes assume that no-one
else has access to the information they have given you. You should therefore
be careful not to share information which you believe the patient might wish to
be private. You may need to check with the patient about what can be shared
with colleagues. You must always respect the patient’s wishes except where
this would put someone else at risk of serious harm.
If you see a patient outside your practice setting (e.g. in a walk-in centre or an
out-of-hours co-operative), you should inform the patient’s GP about the care
you give, unless the patient objects.

The excellent GP
- records appropriate information for all contacts including telephone consultations
- respects the patient's right to confidentiality and provides information to colleagues in a manner appropriate  to their level of involvement in the patient's care
- ensures that letters are legible and copies kept on file
- files GP notes, hospital letters, and investigation reports in date order

The unacceptable GP

-keeps records which are incomplete or illegible, and contain inaccurate data or gratuitously derogatory remarks
- does not keep records confidential
- does not take account of colleagues' legitimate need for information
- keeps records that cannot readily be followed by another doctor
- consistently consults without records