Whilst it’s understandable with increasing pressures on workload that things can be missed or forgotten, documenting a patient’s consultation is important to protect yourself as well as the patient.
In the GMC’s Good Medical Practice (2013) it states in Domain 1: Knowledge, Skills and Performance – “Documents you make (including clinical records) to formally record your work must be clear, accurate and legible…at the same time or as soon as possible after the event.”
So, if it’s not documented there’s no evidence that it happened and make sure the notes are contemporaneous!
Read full document here:
GP PAG bites (NHSE SSW, November 2018).