The importance of clinical record keeping

Good record keeping is essential for all clinical practitioners, to inform themselves, others in their team, other clinicians, the patient and in case of any outsider seeking to understand what happened. The last happens where there is a complaint or threat of legal action. Good practice is simple, logical and need not be time-consuming. It may even improve the clinician’s approach to their practice.

Medico-legal Minder gave a talk in June based on Chapter 8 of Clinical Practice and the Law – a legal primer for clinicians at the Bristol Patient’s Safety Conference 2021. Feedback from delegates confirmed the importance of this knowledge in setting out their “one big takeaway from the conference”:

I think I will alter my record keeping as suggested in legal talk

[It was a] reminder of the importance of note keeping from a legal point of view.

Really enjoyed the ‘Legal’ workshop on the importance of documentation. Incredibly useful to hear from someone with a legal perspective and how they view ambiguous notes. 

The importance of documenting within patient records.

The importance of clear and accurate note keeping.

The talk given about the legal aspect of documentation for patient safety by Giles Eyre was really eye-opening – I will take this with me throughout my career about documenting legibly and clearly by explaining my thought process with important decisions so that if ever read by a lawyer, they will be able to see that I considered all options in the patients best interests. 

Clinical Practice and the Law – a legal primer for clinicians is available to readers of this blog for July at the special price of £19.95 (plus £4.95 p&p) (normal price £34.95) by emailing me, with a delivery address, at