Medical record keeping
Vale of Leven Inquiry · The Vale of Leven Hospital Inquiry Report · Issued 24 November 2014 · Addressed to: NHS Health Boards (Scotland)
Source — verbatim from the inquiry
●Inquiry recommendation
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Vale of Leven Inquiry, The Vale of Leven Hospital Inquiry Report · 24 Nov 2014 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The Scottish Government's response directly addressed this recommendation, emphasising that clear, accurate, and legible patient records by doctors are integral to good patient care.
- The GMC's Good Medical Practice requires doctors to maintain clear, accurate, and legible records that include all relevant clinical findings, decisions, and information given to patients. GMC revalidation (from December 2012) requires doctors to demonstrate compliance with these record-keeping standards.
- The Health and Social Care Standards (published June 2017) encompass professional record-keeping expectations (Health and Social Care Standards (https://www.gov.scot/publications/health-social-care-standards-support-life/)).
Response — verbatim from government
●Scottish Government
Section 4.2 of the Scottish Government's response directly addresses recommendation 38, which relates to clear, accurate, and legible patient records kept by doctors, emphasizing their integral role in good patient care. The General Medical Council (GMC) requires doctors to maintain clear, accurate, and legible records, made at the time of events or as soon as possible. Furthermore, the Scottish Government has developed its own Records Management: NHS code of practice (Scotland), updated in 2012, to guide required standards, and is investing in eHealth systems to improve record-keeping and information sharing across NHSScotland.
Scottish Government · 18 Jun 2015 Written response →
Evidence trail — what's actually happened since
- 1 Jan 2025 · Healthcare Improvement Scotland Excellence in Care framework and NHS Scotland governance standards address medical record keeping requirements. National standards for clinical documentation exist but specific legibility requirements have been partially overtaken by electronic health records adoption. View source → Reasonable Progress
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.