Practice Management, Record Keeping, and Documentation
What a good record contains
A defensible record identifies the patient, date, and author; states the reason for attendance; records relevant history, examination findings, diagnosis, options discussed, consent, treatment provided, materials, and follow-up. It should be objective and free of speculation about the patient's character. Abbreviations are acceptable only if universally understood within the practice.
Systems and safety
Practice-management questions test understanding of recall systems, infection prevention and sterilisation cycles with logged validation, radiation safety and quality assurance, staff training records, and the handling of complaints. Adverse incidents and near-misses should be recorded and reviewed, not buried. Prescribing and dispensing require accurate records of drug, dose, batch, and expiry where relevant.
Traps
Frequent errors: writing a retrospective note to "fill in" a missed entry, recording opinions as fact, omitting the consent discussion, and failing to record advice given by phone. Items also test data protection - sharing identifiable information only with appropriate authority, storing records securely, and knowing retention requirements for the jurisdiction. If you do not know a jurisdiction-specific retention period with confidence, say so rather than guessing.
Rule of thumb
Write as if another clinician will take over tomorrow with only your note: could they continue safely? If the note does not explain why a decision was made, it is incomplete.
Worked example: A patient telephones reporting swelling after an extraction. Record the time, who took the call, the symptoms described, the advice given, and the review arranged - then ensure the clinical entry reflects any subsequent examination.