Patient Records and Documentation Requirements for UK Clinics

In the UK there is no single “patient records act”. Record-keeping requirements for aesthetic clinics come from several places: CQC regulations (for clinics carrying out regulated activities in England), the professional codes of the GMC and NMC, and UK data protection law.

What the rules say

CQC Regulation 17 requires providers to “maintain securely an accurate, complete and contemporaneous record” for each service user, including the care and treatment provided and the decisions taken. The GMC’s Good medical practice (2024) says records must be “clear, accurate, contemporaneous and legible”, and the NMC Code asks nurses to complete records at the time or as soon as possible after an event.

What information should be documented in a patient record?

Good entries are concise but complete, and easy for anyone with access to read and understand. For an aesthetic treatment, the record should normally include:

• Patient identity details
• Relevant medical history and clinical findings
• The consultation and the treatment options discussed
• Consent
• Products used, including batch numbers
• The treatment carried out and any complications
• Aftercare advice given
• Who made the entry and when

What should not be documented in a patient record?

Avoid information about third parties unless it is essential, subjective or derogatory remarks, and abbreviations or internal terms that others may not understand.

Requirements for entries in the patient record

Entries should be made as soon as possible and signed with name, date and time. Records must not be deleted or made illegible; if an entry is wrong, it should be corrected with a new entry so the full history stays visible. Electronic systems should log who accessed or changed a record.

How long should records be kept?

There is no single retention period set in law for private clinics. Many follow the NHS Records Management Code of Practice, under which most adult health records are kept for 8 years after the end of treatment. Check what your insurer or professional body recommends.

Patients’ right of access

Under the UK GDPR, patients can request a copy of their records, and the clinic must normally respond within one month.

Tips for good record entries

Patient records can contain a lot of information, but entries should be concise and straightforward so that everyone reading them can understand. A few guidelines:

• Write concisely, without elaboration or narrative
• Avoid personal judgements
• Where you make a personal interpretation, make it clear
• Write out complete words instead of abbreviations or slang
• Entries should only concern the specific patient
• Where professional contacts are mentioned, give full names and job titles

A system that supports good record keeping

MERIDIQ’s patient records for aesthetic clinics keep treatment notes, consent forms and before-and-after photos in one place, with role-based access and a log of who changed what. Patients can fill in their details before the visit, which saves time and improves accuracy. The system works in the browser and as an app, is priced per user, and comes with a free 14-day trial.