The GMC sets professional standards for keeping records that all doctors should follow.
GMC guidance: record-keeping
'19. Documents you make (including clinical records) to formally record your work must be clear, accurate and legible. You should make records at the same time as the events you are recording or as soon as possible afterwards.'
'21. Clinical records should include:
a. relevant clinical findings
b. the decisions made and actions agreed, and who is making the decisions and agreeing the actions
c. the information given to patients
d. any drugs prescribed or other investigation or treatment
e. who is making the record and when.'
GMC, Good medical practice
What should be documented in the health record
In addition to the principles above, doctors providing non-therapeutic male circumcision (NTMC) are advised to document on the consent form and/or in the main health record:
- Details of the best interests assessment and reasons for making the decision to perform NTMC
- Details of the pre-operative clinical assessment of the child, the procedure, pain relief and anaesthesia and aftercare
- Details of any discussions with the child or young person, and those with parental responsibility
- What information was offered to the boy and his parents
- If a second opinion was requested, details of that request and of the response
- Details of any legal advice sought
As noted on our guidance on consent and refusal, doctors are strongly advised to obtain written consent for NTMC. Consent should be obtained from both parents, other than where a child has only one parent.
As well as being fundamental to good clinical practice to support patient care, good documentation will also be useful for clinical audit and monitoring performance. Data quality and accuracy are essential in order for records to be effective for such purposes.
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