Good clinical records are a prerequisite of delivering high-quality, evidence-based healthcare, particularly where a number of different clinicians are contributing simultaneously to patient care. Everyone involved in a patient’s clinical management should have access to the information they need – otherwise, duplication of work, delays and mistakes are inevitable.

Records may be held electronically or manually, or a mixture of both. Some healthcare professionals – for example physiotherapists, occupational therapists, speech therapists and psychologists – often maintain separate departmental records, sometimes (but not always) copying important information relevant to others into the main hospital record.

But in any event, a patient’s clinical record is never a single document. Increasingly, GPs hold their records in computerised form and many hospitals hold a mixture of electronic and paper records. These should be cross-referenced with other files that may exist in various departments.