Record-keeping for GP locums: three tips for better notes

20th September 2021 by Dr Rachael Birch

Record-keeping for GP locums: three tips for better notes

It is very likely that general practice will be seeing a busier September than usual. There will no doubt be those who have been saving up their health concerns until after they are double vaccinated. Some patients, perhaps even those more vulnerable, may choose this summer as the safest time to consult with their GP.

Despite the success of the vaccination programme, it is evident that general practice is unlikely to revert to a pre-Covid way of working, at least not for a very long time. Sessional GPs will therefore find themselves continuing to consult with patients by a combination of telephone, video and face-to-face consultations.

GMC: five points

Irrespective of the way you consult with patients, good record-keeping is essential to reduce risk and improve outcomes for patients. The General Medical Council’s ‘Good medical practice‘ advises doctors to write clear, accurate medical records, at the same time as the events you are recording or as soon as possible afterwards.

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