Record keeping

Basic documentation guidance is described in the GMC’s Good Medical Practice 2024 Domain Three Sections 69-70

 

  • Record your work clearly, accurately, and legibly
  • You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous, and legible.
  • You should take a proportionate approach to the level of detail, but patients’ records should usually include:
    • relevant clinical findings
    • drugs, investigations, or treatments proposed, provided, or prescribed
    • the information shared with patients
    • concerns or preferences expressed by the patient that might be relevant to their ongoing care, and whether these were addressed
    • information about any reasonable adjustments and communication support preferences
    • decisions made, actions agreed (including decisions to take no action) and when/whether decisions should be reviewed who is creating the record and when.

 

These have altered from the previous iteration, and the greater emphasis on shared and agreed decision making is especially important when the potential long-term use of opioid medication is being considered.

 

Additional considerations when prescribing opioids

For prescription of opioids there should a focus on:

  • The aims of treatments – this may include allied aspects such as function
  • The drug and formulation(s) – e.g., modified release and immediate release
  • Any guidance (oral and/or written) on use and patient choices (e.g., dose escalation/reduction, PRN options) – where provided
    • Best practice is to provide written guidance and/or address this in correspondence to the patient and GP.
  • the means of assessing the aims
  • the timescale of reviews
    • these should be frequent until stability of treatment and outcome are apparent

  • the management of the outcomes

    • From the outset there should be clear criteria for the optimisation, reduction and/or stoppage of the medications and how this may be achieved

     

It should be clear that this is an agreed plan of management between the patient and the prescriber.

 

Further reading: 

Good practice in prescribing and managing medicines and devices (gmc-uk.org)

The National Institute for Health and Care Excellence (NICE). Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. NICE guideline [NG215], 2022.

Other resources in this section

Opioids Aware homepage