Documentation in Prescribing

Why is documentation essential in healthcare?

It supports patient safety, continuity of care, legal accountability, protection, transparency, and MDT communication.

How does documentation improve patient safety?

By reducing errors and supporting accurate clinical decision-making and follow-up.

What role does documentation play in continuity of care?

It allows other healthcare professionals to understand previous decisions and care plans.

Which professional frameworks guide documentation standards?

RPS Competency Framework and NHS Record-Keeping Standards.

Name key legal requirements related to documentation.

• Medicines Act 1968

• Human Medicines Regulations 2012

• Misuse of Drugs Regulations

• Data Protection Act / GDPR.

What patient information must always be documented?

Patient identifiers

What prescribing details must be recorded?

Drug name, dose, route, and frequency.

What clinical details should be included in records?

• Clinical assessment or diagnosis

• Monitoring and follow-up plans

• Decision-making rationale.

Why should patient discussions and consent be documented?

To demonstrate informed consent and shared decision-making.

What are the features of good documentation?

• Clear

• Concise

• Dated

• Signed

• Contemporaneous.

What characterises poor documentation?

Vague entries, missing rationale, late entries, and alterations.

Where does accountability lie in documentation?

With the prescriber’s signature and clinical notes.

What are the advantages of electronic records?

Legibility, audit trails, and improved access.

What risks are associated with electronic documentation?

System downtime and copy-forward errors.

What GDPR principle applies to clinical documentation?

Only necessary information should be recorded, with secure access controls.

How does documentation support clinical governance?

It enables audit, quality improvement, and mandatory reporting.

What are the professional consequences of poor documentation?

GPhC disciplinary action, NHS legal liability, and negligence claims