Working with doctors Working for patients

Keeping records

Key points

  • Keep clear, accurate and legible records.
  • Make records at the time the events happen, or as soon as possible afterwards.
  • Record your concerns, including any minor concerns, and the details of any action you have taken, information you have shared and decisions you have made relating to those concerns.
  • Make sure information that may be relevant to keeping a child or young person safe is available to other clinicians providing care to them.