Revalidation and the quality of medical note keeping

Guidance for the use of evidence of the quality of medical note-keeping for consultant revalidation has been developed by the Health Informatics Unit (HIU). It was developed with wide consultation including online questionnaires and clinician workshops.

What we are doing

All doctors in the United Kingdom are legally required to be registered and hold a licence to practise medicine. Licensed doctors will be required to demonstrate to the General Medical Council (GMC) that they are practising in accordance with the generic standards of practise set by the GMC. This will provide patients and employers regular assurance that doctors are up to date and fit to practise. Medical notes are an important part of clinical practice.

  • They are the record of information about a patient’s condition, investigation and treatment upon which decisions about their care are made.
  • They are the essential permanent records that form the basis of communication between healthcare professionals, supporting patient safety and continuity of care.
  • Errors and omissions in clinical records are frequently related to clinical incidents, in particular those that come to litigation and also to GMC fitness to practice panels.
  • Patients expect them to be accurate and complete.

This project produced guidance to assess generic aspects of medical note keeping for appraisal and revalidation purposes. This guidance published in April 2011 covers the quality of the written entries (that they are legible, accurate, dated, signed, etc). It specifically does not cover the clinical content of those entries necessary to demonstrate appropriate levels of care or clinical outcome.

Throughout the process of drafting the guidance, the Health Informatics Unit (HIU) ensured extensive clinical engagement and specialist contribution to the development of the guidance. This has included extensive consultation with all the medical royal colleges, specialist societies, and patients and carers.

The objective of this work was to provide consensus-based guidance on how information on quality of medical note keeping can be used in supporting information at appraisal for revalidation.

This revalidation guidance project was funded by the Academy of Medical Royal Colleges (AoMRC).

One of the recommendations of the guidance is that the quality of record keeping should be audited. A suitable audit tool is the ‘stand-alone’ generic multidisciplinary record keeping audit tool developed for auditing clinical records against the generic health record keeping standards.

The RCP offers specialty guidance, advice and resources for revalidation.