Annex - Extracts from Good medical practice

66. You must be confident that any person you delegate to has the necessary knowledge, skills and training to carry out the task you’re delegating. You must give them clear instructions and encourage them to ask questions and seek support or supervision if they need it. 

67. If a task is delegated to you by a colleague but you’re not confident you have the necessary knowledge, skills or training to carry it out safely, you must prioritise patient safety and seek help, even if you’ve already agreed to carry out the task independently. 

68. You must follow our more detailed guidance on Delegation and referral.

69. You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous³  and legible. 

70. You should take a proportionate approach to the level of detail but patients’ records should usually include:

1. relevant clinical findings
2. drugs, investigations or treatments proposed, provided or prescribed 
3. the information shared with patients 
4. concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed
5. information about any reasonable adjustments and communication support preferences
6. decisions made, actions agreed (including decisions to take no action) and when/whether decisions should be reviewed
7. who is creating the record and when.

71. You must keep records that contain personal information about patients, colleagues or others securely, and in line with any data protection law requirements and our guidance on Confidentiality: good practice in handling patient information