C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

  1. Records help you to provide good-quality care to your patients and should include:
    1. date of the consultation
    2. patient’s personal details
    3. any problems, symptoms, concerns and priorities discussed with your patient
    4. relevant medical, family and social history
    5. your clinical findings
    6. the information and advice you provide, including a record of how this is communicated to your patient
    7. a working diagnosis and treatment plan
    8. records of consent
    9. any treatment you undertake
    10. any communication with, about or from the patient
    11. copies of any correspondence, reports, test results, etc relating to the patient
    12. clinical response to treatment and treatment outcomes
    13. the location of your visit if outside your usual consulting rooms
    14. whether any other person was present and their status
    15. where an observer is present (for example, a chaperone, peer observer, osteopathic student, or potential student) as well as their status and identity, you should record the patient’s consent to their presence.
  2. Your notes should be contemporaneous or completed promptly after a consultation (generally on the same day).
  3. The information you provide in reports and forms or for any other purpose associated with your practice should be honest, accurate and complete.