Documentation
The importance of clinical documentation
Medical records are crucial facet of a patient’s journey and is central to good clinical practice. This record of medical information assists in optimising patient care by:
- Safeguarding continuity of care by providing information to colleagues involved in care and treatment
- Ensuring service users receive appropriate treatment that is in their best interests
- Meeting legal requirements or respond to Freedom of Information or Subject Access Requests
- Supplying data for audits and research
- Evidencing your decision-making processes if later queried or investigated.
