Audit of GP Consultation Records for Quality Improvement

Abstract

This review outlines a multi-centre quality improvement (QI) project conducted to assess the accuracy of General Practitioner (GP) consultation records across three clinical sites in Manchester, UK: Practice A, Practice B, and Practice C. The audit aimed to ensure compliance with the General Medical Council’s (GMC) guidelines for good medical practice in clinical record-keeping. Three – five patient records per clinician were reviewed over a four-week period. The audit assessed the completeness of documentation concerning clinical findings, patient history, prescribed treatments, and referrals. A second audit cycle followed targeted feedback and action plans. Results showed significant improvements in the accuracy of record-keeping across all three sites, emphasising the effectiveness of regular audits and feedback. Re-audit cycles are recommended based on accuracy scores to ensure continuous improvement. This review highlights the importance of clinical audits in maintaining high standards of documentation, improving patient safety, and good record keeping.