FROM POST-ITS TO PLATFORMS: THE IMPORTANCE OF GOOD RECORD KEEPING
Let’s be honest - pharmacy life is a whirlwind. One minute you are dispensing medicines, the next you are knee-deep in a clinical consultation that started as a casual chat about a minor problem.
By Dr John Freestone, Director DigiPharma
W
e are the frontline of healthcare, juggling multiple roles at once. While patient care is always the priority,
there is one aspect of our work that often gets overlooked but is absolutely essential: good record-keeping.
Why Good Notes Matter You know the story - a patient pops in with a question about a cough. You ask a few questions, give some advice and they walk away reassured - but what happens when they come back a month later with worsening symptoms? If you have documented the initial conversation properly, you are not starting from scratch. You have context, which makes all the difference in providing continuity of care.
Record keeping is not just about covering yourself legally (though that is a big plus); it is about building trust and ensuring patients get consistent, high-quality care. Good record keeping also makes our jobs easier when we don’t have to rely on memory alone!
The Legal Side: Storing Clinical Records for 8 Years Beyond patient care, there is also the regulatory side. In the UK, any clinical encounter must be stored for up to eight years – it is one of the biggest reasons we started DigiPharma. This is in line with guidelines from the General Pharmaceutical Council (GPhC) and the NHS, ensuring accountability and patient safety.
Imagine a scenario where a patient challenges the advice you gave them months or even years ago. Without clear records, it is your word against theirs. With proper documentation, however, you have the evidence to back up your decisions. Having good notes can protect you in case of complaints, audits or legal issues.
Making Life Easier The reality of our current practice may be keeping scraps of paper in a folder, or in a spreadsheet as a work around, but this is not practical anymore, not with the volume increasing day-on-day. The PMRs give you a small free text box to document the case but this is not enough. It is messy, time- consuming, unsafe, slow and things get lost, leading to poor record keeping and lost revenue.
DigiPharma provides the ability to log consultations quickly, send communication to other healthcare providers, write private
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scottishpharmacist.com
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