records in general practice

Last reviewed 01/2018

General practice records consist of:

  • consultation records plus:
  • registration data
  • reminders and recalls
  • personal data
  • repeat medication list
  • past medical history summary
  • family history
  • health promotion data
  • hospital and community team communications

More and more records are being kept on computers for ease of transmission, speed of access and availability. All information relevant to each patient's care, including all diagnoses, home visits, medication and administrative notes, are put into the patient's computer notes. This is vital to allow continuity of care by all team members at any site at any time. Paper records can only be in one place at any one time and are therefore fast becoming obsolete as patients', lawyers', and especially doctors' own expectations rise.