01 July 2014
Good record keeping ensures that clinicians and other staff can readily access information to provide efficient and high quality care. It facilitates continuity of care whilst informing and justifying decision making in a manner that it is clear to all. In the event of complaints, untoward incidents and medico-legal cases, accurate and comprehensive documentation supports efficient resolution. In addition, good clinical records support audit, management, planning, policy, commissioning and research.
Please read this guidance document in conjunction with any relevant clinical statements for this topic.
These can be found by visiting the Clinical Statements section.