Clinical documentation

Pharmacy guide

This pharmacy guide will help you with why, when and where to make a clinical record.

It also gives examples of clinical records that are detailed but concise, legible, contemporaneous and accurate.

This guidance covers documentation of clinical activity such as findings, interventions, referrals, reviews, consultations, prescribing, administering, service delivery, decisions and advice. It does not cover record keeping such as CD records, emergency supplies, private prescriptions, errors, etc. Information on these can be found in the MEP.

^{First Published: 10 September 2020
Updated: 13 August 2025}