Clinical Recordkeeping and Documentation
This domain tests the quality and legal status of the clinical record. Examiners probe what must be recorded, how corrections are made, who owns the record, and how long it is kept.
Core rules and concepts
- Records should be contemporaneous, accurate, legible, attributable, and complete. The minimum dataset includes history, examination findings, diagnosis or impression, advice, treatment, referrals, and consent discussions.
- Negative findings and advice given matter. Recording that a patient declined referral, or that risks were explained, can be decisive later.
- Amendments must be dated, signed, and identified as additions or corrections. The original entry should remain visible; backdating or overwriting is falsification.
- Electronic records must preserve an audit trail. Access controls and passwords must not be shared.
- The practice generally owns the physical or electronic record, while the patient has rights of access. Retention periods are set locally; adult records are commonly kept for several years after the last visit, and minors' records until majority plus a further period.
Worked example
After an adverse event, an optometrist realises a referral was not recorded. Adding a note dated on the day of the original consultation would be backdating. The correct approach is a late entry dated today, stating what is being added and why, without obscuring the original. The reasoning is that the record is a contemporaneous account, and a transparent late entry is far less damaging than a fabricated timeline.
Traps that cost marks
- 'If it is not written down, it did not happen' applies to advice and refusals as well as findings.
- Using ambiguous abbreviations that other clinicians cannot interpret.
- Destroying records too early or after a complaint has been signalled.
- Sharing login credentials in an electronic system.