Record keeping and prescribing

Most non-medical prescribers will normally be alone with the patient during the consultation, whether that takes place in the surgery, home, ambulance or over phone or video call. In face-to-face consultations, your clinical notes may be the only records of the event. In most organisations, telephone calls are recorded and emails can be used to provide hard copy evidence. Skype is also recorded centrally and is backed up in the cloud so this again may be used in evidence. Patients may covertly record consultations and you are advised by many professional bodies that should you become aware of this, you should encourage the patient to be open about this and you can ask for a copy of the recording for your records.

Occasionally, consultations are video recorded when the clinician has a body camcorder or video camera. This could be used and replayed into a court room, either by you in your defence or by the patient to support their grievance, negligence claim or a criminal act. You should be extra cautious with doorbells that have video capability and internal cameras that are linked internally to a WiFi hub. It is often forgotten that not only can someone be watching live from anywhere in the world that has an internet connection, but these smart devices are also capable of recording sound in a high-quality format, which means your conversations are being recorded and can be played back later with sufficient quality to be used in evidence.