Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to accurately record progress notes and risk assessments
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Remind staff to validate records and routinely audit unvalidated notes, providing audit feedback to clinical teams.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Extend mandatory clinical risk management training to cover the revised mental-health risk assessment and management procedures.
Stated by Midlands Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Automatic validation of all electronic records is not achievable because some staff entries must be validated by other staff.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Failure to record contemporaneous clinical notes, including presence or absence of suicidal ideation
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inaccurate and misleading care records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement procedures for resident observations, recording, communicating treatment requirements to relatives, and reporting baseline changes to professionals.
Stated by Brancaster Care Homes Limited -
Action
Train all registered nurses to complete contemporaneous records in accordance with NMC guidelines.
Stated by Brancaster Care Homes Limited -
Action
Conduct scheduled monthly internal and external audits of care records.
Stated by Brancaster Care Homes Limited
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Concerns raised1
Failure to record significant clutter and associated risk in clinical notes
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record the consultation about the impact of the ADHD diagnosis
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to make full and appropriate clinical records of physical examinations and resulting actions
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Train and remind staff to document incident monitoring, physical examinations, actions taken, and handovers promptly and clearly.
Stated by Zinnia Healthcare Limited
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Concerns raised1
Gaps in clinical documentation and record keeping
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Deficient GP record-keeping practices
Deficient GP record keeping
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to enter timed ward-round dictated notes in chronological order
Failure to record clinician input following escalation in clinical notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Inadequate processes for recording test results in electronic patient records
Poor medical record keeping
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Use updated diagnostic-result processes to action results on receipt, arrange follow-up for results requiring it, notify patients appropriately, and audit actions in clinical records.
Stated by Stonefield Street Surgery -
Action
Refresh doctors’ knowledge of GMC record-keeping guidance and improve the detail of clinical documentation.
Stated by Stonefield Street Surgery
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Test results were clearly visible in the electronic record, contrary to the concern that results were not appearing within patient records.
Stated by Stonefield Street Surgery
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Position
Existing diagnostic-result processes ensure tests are actioned on receipt, abnormal results are followed up, and actions are auditable.
Stated by Stonefield Street Surgery
Data last updated 7 September 2026