Communication C11

To assess a patient clinically, in OPD and elsewhere, in particular to:

TITLECLINICAL RECORD KEEPING

Code

C11

Learning Outcome

  • Keep accurate, succinct, contemporaneous and legible clinical records.
  • Ensure all relevant information is recorded following local and GMC guidelines.
  • Use appropriate, secure electronic records.
  • Be aware of the security and patient confidentiality of every record.

Assessment

CbD MSF Portfolio Part 2 FRCOphth 

Assessor

Feedback likely from: medical staff, Allied Health Professional (nurse, optometrist, orthoptists), secretarial and clerical staff

Target Year of Achievement

Year 2 (annual review)

Related Learning Outcomes

Overview

  • Seek feedback from a colleague after they have scrutinised one of your patient records.

Resources

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