Record Keeping
Keep accurate and detailed records and record the following:
- Nature of any health problem, with details of any injuries and symptoms any concerns you may have
- What the patient says and not what you think, although it is important to note any concerns or suspicions
- Outcome of risk assessment
- Any action taken or advised
Think back to Marisca's story:
What notes should the GP have made about her case?
- Appeared frightened
- 7 months pregnant
- Is distressed about pregnancy
- Is very concerned about a possible Sexually Transmitted Infection
- Displays signs of mental health issues
- Accompanied by man doesn't seem to be happy that she was seen alone
- Note of address
- Referred on to Social Services