Clinical documentation
Guidance on why, when and where to make a clinical record, with examples of clinical records.
Published: 10 September 2020
Updated: 13 August 2025
Sections on this page
- What is clinical documentation?
- Why keeping clinical records of findings, advice and decisions is important
- Who is responsible for clinical documentation?
- When to make a clinical record
- Where and how to make a clinical record
- Practical guidance for writing clinical records and electronic communication
- Examples of some clinical records and what to include in them – medicines reconciliation, history taking, medication reviews and SMRs, prescribing and advice
- Further information