The GMC expects, as outlined in their Good Medical Practice Guide, clinical records to include relevant clinical findings, the decisions made and actions agreed, and who is making the decisions and agreeing the actions, the information given to patients, any drugs prescribed or other investigation or treatment and who is making the record and when.
During a CQC visit or call, you can expect the inspector to review a sample of consultation records to check the notes are written contemporaneously, contain the information above including clinical findings, decisions made and actions agreed, and medicines are appropriately prescribed.
We have developed a consultation audit you can use for any clinicians, along with an action plan and proposed re-audit intervals.
How QCS can help you further with quality improvement