Keeping clear medical records is a professional requirement and an integral part of good quality care. Given the sensitive information medical records contain, maintaining their security and privacy is vital. Good documentation can also substantially improve the defensibility of a claim or complaint.

This online workshop explores:

• how to create logical and appropriately-detailed clinical notes
• the medico-legal requirements around when and how to release information in medical records to others
• how to recognise common problems with medical records that can adversely affect patient care and medico-legal outcomes
• appropriate management of unsolicited information provided about a patient by a third party
• secure storage and retention of, and access to, medical documentation.

This activity is approved for continuing professional development (CPD) with a number of medical colleges.