4.4 Record keeping, confidentiality and information sharing

GP computer systems provide a structure for systematically recording the clinical findings and decisions made during the consultation. Pharmacy systems are changing but not all pharmacists have access to such a structure and may instead have a single free text box.

In this situation, consistently using a structured format ensures that important information has been captured in a way that fits with other entries in the primary care clinical record. The GP, when looking at  the record, needs to be able to rapidly glean the key information.

Further reasons for using a structured format are that in the case of any challenge to your decision-making, it can help justify your actions and reduces the chance of important information not being recorded. A general rule of thumb is that in the eyes of the law, if a detail is not recorded, it cannot be proven to have happened. This includes negative findings.

Two structures commonly used for recording are SOAP and SBAR:

• (S) Subjective, (O) Objective, (A) Assessment and (P) Plan, and
• (S) Situation (B) Background (A) Assessment (R) Recommendation.

They might sound rather simplistic, but have been in use for many years and have stood the test of time. Table 3 on the next page provides some more detail.