Clinical documentation

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Here’s a guide to help you in your practice on why, when and where to make a clinical record. 

It also suggests what to include in some examples of clinical records to make sure they are detailed but concise, legible, contemporaneous and accurate. As the settings in which pharmacists work is wide-ranging, general guidance is provided but specific recommendations are also given where necessary.

This guidance covers documentation of clinical activity such as findings, interventions, referrals, reviews, consultations, prescribing, administering, service delivery, decisions and advice. It does not cover record keeping such as CD records, emergency supplies, private prescriptions, errors etc. Information on these can be found in the MEP.

First Published: 10 September 2020
Updated: 28 January 2022

Sections on this page

  • What is clinical documentation?
  • Why keeping clinical records of findings, advice and decisions is important
  • Who is responsible for clinical documentation
  • When to make a clinical record
  • Where and how to make a clinical record
  • Practical guidance for writing clinical records and electronic communication
  • Examples of some clinical records and what to include in them - medicines reconciliation, history taking, medication reviews and SMRs, prescribing and advice
  • Further information

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