Clinical records procedure
SOP template
Check this template against your local regulations and your own policies before you use it.
| SOP no. | Version | Effective date | |||
|---|---|---|---|---|---|
| Owner | Approver | Review date |
Purpose
To make sure every patient’s record is accurate, complete, written on time and kept secure.
Scope
Every clinical record made by any clinician at the practice, on paper or electronically.
Responsibilities
| Role | Responsibility |
|---|---|
| Clinicians | Write complete notes for every consultation on the day. |
| Practice manager | Manages access, requests and retention, and audits notes. |
Procedure
Record the assessment
Record the history, findings, diagnosis, goals, plan and the consent given.
Record every treatment
Record the date, what was done, the patient’s response, any advice or exercises, and the plan.
Write on the day
Write notes during or straight after each session, and always the same day.
Correct, don’t delete
Add a dated correction rather than changing or deleting an earlier entry.
Keep records secure
Use your own login, lock screens, and never take records off-site unsecured.
Handle requests
Give patients access to their records and transfer them to other providers as the privacy law allows, with written consent.
Caution: Check the requester’s identity before releasing any record.
Keep and dispose
Keep records for as long as your local rules require, then destroy them securely.
Records
- The clinical record for each patient.
- The register of access and transfer requests.
Related documents
- Patient consent procedure
Revision history
| Version | Date | What changed | Approved by |
|---|---|---|---|
