How to record patient notes on a PMR: what to write, what to attach, and how long to keep it

What are patient notes for?

Structured data answers the questions a service knew to ask when it designed its forms. Notes hold everything else, and the two do different work.

A weight is a fact. Whether the patient seemed to understand the dose escalation, why the prescriber accepted a marginal case, what the patient said about their previous attempt, and what they were told to do if a side effect appeared, are not facts of that kind and cannot be captured as values. They are also, when a decision is questioned, the material the question is actually about.

This is where the regulator's April 2026 finding usually lands. Incomplete or insufficient consultation records rarely means the measurements were missing, since those are the easy part and the form insists on them. It ordinarily means the record shows what was done and not why it was reasonable, and the reasoning is the part which lives in notes.

How do you write a good patient note?

Four elements cover most consultations. What was found, where it is not already a field. What was decided, and the reasoning, particularly where the case was not straightforward. What the patient was told, including warnings and what to do if something changes. And what happens next, comprising the review interval, the follow up and any condition attached to continuing.

What should you never write in a patient note?

Four things, and each causes a specific problem.

Measurements which should be fields. A weight in a note is prose rather than a series, and cannot be charted, compared or reported, per the data capture guide.

Speculation about the patient's motives. A note recording that a patient's answers were inconsistent is a clinical observation. A note speculating that they were lying is a judgement which reads badly to the patient, to a reviewer and to anyone else who eventually sees it, and it adds nothing the first formulation does not.

Third-party information without care. Details about a patient's family member belong in the record only where clinically relevant, because they are that person's data as well.

Commercial reasoning. A note referencing revenue, targets or retention alongside a clinical decision creates exactly the impression the whole governance framework exists to dispel, and it will be read that way whatever was meant.

Where should patient documents and photographs be stored?

Attachments are where good record-keeping most often leaks, because they arrive through channels nobody designed.

A patient emails a photograph. A GP faxes or posts a letter. Someone screenshots a message. Each of those ends up somewhere, and the somewhere is frequently a shared inbox, a member of staff's phone, or a folder on a desktop. That is a data protection problem before it is a records problem, since images of a person or a condition are special category data and none of those locations is a controlled record.

Four rules keep it manageable. Everything attaches to the entry it supports, so the photograph sits on the consultation it informed rather than in a general patient folder. Nothing lives in an inbox, which means the workflow must give staff somewhere better to put it within the same minute. Nothing is publicly reachable, since uploads sitting at guessable addresses without authentication is among the most common findings in any website review, as the security baseline notes. And the file is retained rather than a description of it, because a note saying photograph reviewed is not the photograph.

Where a service accepts patient photographs routinely, it should say so on the page which invites them, explain what happens to the image, and offer a route for patients who would rather not send one.

Can you edit or delete a patient note?

Every note carries who wrote it and when, and that is not administrative detail. In a service with multiple prescribers, locums and support staff, the identity of the author is frequently the first thing a reviewer wants and the thing shared logins destroy.

Notes are not edited. Where something is wrong, the correction is a new entry explaining what was incorrect and why, with the original left visible. Two reasons, and the second is the one usually overlooked. A record which can be silently altered is not evidence, so amendment history is what gives the current version any weight at all. And the fact that something was corrected is itself clinically informative, since a value amended after a decision was made on it tells a different story from one corrected before.

This sits alongside a patient's right to have inaccurate personal data rectified, which is discharged by recording the correction rather than by erasing what was previously held. Rectification and deletion are different things, and a service which handles the first by doing the second has removed the trail which shows it acted properly.

Can patients see what you write about them?

Individuals have a right of access to their personal data, and clinical notes held about them fall within it. The practical consequence is simple and worth stating to every person who writes notes.

Write every note on the assumption the patient will read it. Not because they usually will, but because the notes which cause difficulty are almost always the ones written as though they would not. A note which is accurate, clinical and free of editorialising reads well to a patient, a reviewer and a solicitor alike. A note containing a dismissive aside reads badly to all three, and the aside was never doing clinical work in the first place.

Limited exemptions to access exist, including where disclosure would be likely to cause serious harm or would reveal information about a third party who has not consented. They are narrower than services tend to assume and any reliance on them warrants advice on the specific case rather than a general policy.

How long do you keep patient notes?

Notes and attachments retire with the record they explain rather than on a shorter schedule of their own. Keeping the structured data whilst purging the notes leaves a record which shows what was supplied and cannot show why it was appropriate, which inverts the value of what was kept.

Three requests recur and each has a different answer. The patient asking for their own records is exercising a right and should receive a coherent file rather than a data dump. A third party asking, comprising an insurer, employer or solicitor, needs the patient's specific written authority, and disclosure should be limited to the scope that authority covers, as the consent article sets out. A regulator or investigator asking is a different footing again and warrants prompt advice rather than an immediate response assembled under pressure.

One migration point applies as it does to consent. Notes and attachments must survive a change of system, so they belong in any export taken before migration and should be confirmed readable afterwards.

How to keep note quality up when you are busy

Note quality collapses under time pressure, and the answer is design rather than exhortation.

Make the structured fields carry the routine. Every fact captured as a field is a fact nobody has to type into a note, which leaves the note for the part only a person can write.

Use prompts rather than templates. A template produces identical notes which say nothing, and identical notes across many patients are worse than short ones because they suggest the record was generated rather than considered. A prompt asking what was decided and why produces a real answer.

Write it before the next patient. Contemporaneous carries the most weight, shortly afterwards is normal, and days later is thin. Where a note is added late, saying so is more defensible than presenting it otherwise.

Audit a sample. Reading a handful of notes each month against the colleague-who-was-not-there test tells a superintendent more about the service than most reports, and it is the cheapest quality check available.

Key takeaways

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