Record keeping and communication

This CPD module looks at how to record an appropriate summary of a clinical consultation that takes into account the needs of those who will use the record including other primary care professionals as well as patients. 

It will highlight both the structured approach used in GP clinical systems and key legal aspects of record keeping. The module will also cover communication with patients including using dedicated software.

Key facts 

• Recording the necessary detail from a clinical consultation without over-writing requires practice. Striking a balance between completeness and succinctness is key
• SOAP is a structure for recording clinical consultations based on: Subjective, Objective, Assessment and Plan
• All patients have the right to access their clinical record. Never record something that you would not want a patient to see
• If you wish to add to a patient’s medical record or make amendments after the consultation, record the date of any changes and add your signature. Do not try to alter the original record
• Using a computer during a consultation needs to be done carefully. It is important to try to keep this activity separate from engaging with the patient.

Contributing authors: Professor Alison Blenkinsopp and Dr Martin Duerden