Quality
standards for medical records in the Northern Deanery
The following standards apply to manual and computerised records.
- All medical records and hospital correspondence must be filed in practice notes, in date order.
- Appropriate medical records must contain easily discernible drug therapy lists for patients on long term therapy.
- All records should contain medical summaries.
- Practices should be seen to reach these targets prior to appointment and also have mechanisms in place to maintain these standards after appointment.
- Records should be available and used at all doctor/patient contacts.
- Entries should be legible, and where suitable a structured format should be followed.
- Up-to-date preventive medicine and health promotion data should be available during the consultation.