Recording decisions

Keeping patients’ medical records up to date with key information is important for continuity of care. Keeping an accurate record of the exchange of information leading to a decision in a patient’s record will inform their future care and help you to explain and justify your decisions and actions.

You should take a proportionate approach to the level of detail you record. Good medical practice states that you must include the decisions made and actions agreed - and who is making the decisions and agreeing the actions - in the patient’s clinical records. This includes decisions to take no action.

If you make a recording as part of a patient’s care you must follow our guidance on Making and using visual and audio recordings of patients. Such recordings form part of the medical record and should be treated in the same way as other records.

Recordings made by patients are owned by them and do not have to be stored with their medical records.

Consent forms can be a helpful prompt to share key information, as well as a standard way to record a decision that can make regular review easier. They can also be used to review decisions made at an earlier stage, and the relevant information they were based on.

But, filling in a consent form isn’t a substitute for a meaningful dialogue tailored to the individual patient’s needs.