High-quality clinical notes are important to ensure the accurate documentation of the consultation and provide pertinent information for other clinicians. Auditing notes helps identify areas of weakness, drives quality improvement and will result in improved patient outcomes. All doctors should have their notes audited at least once every three years, either by submitting them to the College (mandated for some), or having them checking by an MD or other appropriate person.
Those required to submit notes for audit to the College
The following must submit notes to the College for audit:
- Registrars (within three months of joining the training programme, and subsequently every three years unless advised otherwise by the DCT).
- Fellows who are not undergoing a regular review of clinical notes elsewhere (see below).
- Doctors completing a regular practice review.
- Doctors who have been told to submit notes for College audit by the PSC.
Notes submitted to the College for audit counts as one audit for recertification purposes. Details of how to submit notes for audit can be found here.
Notes review alternative option
The following may have their notes assessed by an appropriate person, though this review does not count as an audit for recertification purposes:
- Fellows working in an accredited Urgent Care Clinic who have been granted an exemption (use this form). The Medical Director regularly performs internal audits of note quality.
- Fellows working in other locations who have received College dispensation (use this form) for their notes to be marked by an appropriate person in the workplace.
In all cases, comments and feedback should be recorded, reviewed, and action taken to make the necessary adjustments. The feedback and actions taken (or to be taken) should be discussed at the annual conversation and may be claimed as CPD. If the Medical Director/appropriate person feels the doctor’s notekeeping is below the standard required, they may discuss their concerns by emailing firstname.lastname@example.org.
Those who have their notes assessed in house must complete an alternative audit of your choosing as your annual audit for recertification purposes.