C2. Ensure that your patient records are full, accurate, legible and completed promptly.
- Records that are accurate, comprehensive and easily understood will help you provide good care to your patients. These records should include:
- Date of the consultation.
- Patient’s personal details.
- Any problems and symptoms reported by your patient.
- Relevant medical, family and social history.
- Your clinical findings.
- The information and advice you provide, and how this is provided.
- A working diagnosis and treatment plan.
- Records of consent.
- Any treatment you undertake.
- Any communication with, about or from your patient.
- Copies of any correspondence, reports, test results, etc. relating to the patient.
- Clinical response to treatment and treatment outcomes.
- The location of your visit if outside your usual consulting rooms.
- Whether any other person was present and their status.
- Where an observer is present (for example, an osteopathic student, potential student or peer observer) as well as their status and identity, you should record the patient’s consent to their presence.
- Your notes should be contemporaneous or completed promptly after a consultation (generally on the same day).
- The information you provide in reports and forms or for any other purpose associated with your practice should be honest, accurate and complete.
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