Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
- The Scottish Government's response directly addressed this recommendation, emphasising that clear, accurate, and legible patient records by doctors are integral to good patient care.
- The GMC's Good Medical Practice requires doctors to maintain clear, accurate, and legible records that include all relevant clinical findings, decisions, and information given to patients. GMC revalidation (from December 2012) requires doctors to demonstrate compliance with these record-keeping standards.
- The Health and Social Care Standards (published June 2017) encompass professional record-keeping expectations (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
How was this evidence gathered?
Response
Accepted
Response
AcceptedSection 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council (GMC) requires doctors to maintain clear, accurate, and legible records, made at the time of events or as soon as possible. Furthermore, the Scottish Government has developed its own Records Management: NHS code of practice (Scotland), updated in 2012, to guide required standards, and is investing in eHealth systems to improve record-keeping and information sharing across NHSScotland.
Published Evidence
Published assessments of progress from inspectorates, select committees, official progress reports, and other sources. Source type badge indicates whether each assessment is independent or government self-reported.
Excellence in Care framework and NHS Scotland governance standards address medical record keeping requirements. National standards for clinical documentation exist but specific legibility requirements have been partially overtaken by electronic health records adoption.
View detailed findings
Electronic health record systems being rolled out across NHS Scotland address legibility concerns. National standards for clinical documentation exist through multiple frameworks.