GMC Record Keeping and Professional Duties

Use this page for General Medical Council (GMC) source-layer evidence about doctors' professional record keeping, consent, confidentiality, candour, patient communication, and decision records.

Source-Layer Position

GMC material supports the professional-duty layer for doctors. It explains what doctors should record and how professional judgement, consent, confidentiality, candour, and patient communication should be evidenced in the record.

What It Supports

Area	Supported record evidence
Clinical findings and assessment	Clear, accurate, contemporaneous, legible records of clinical findings, relevant information, decisions, actions, and review timing.
Consent and decisions	Information offered, options, risks, benefits, alternatives, patient questions, preferences, concerns, decisions, and refusal or agreement.
Confidentiality	Professional handling of confidential patient information and disclosure boundaries.
Candour	Explanation, apology, information shared, follow-up, and record of what happened when things go wrong.
Patient voice and accessibility	Patient concerns, preferences, reasonable adjustments, and information shared in a suitable form.

What It Does Not Prove

GMC evidence does not prove provider governance, local policy, Data Protection Act compliance, DSIC compliance, HealthShare configuration, Health Connect mediation, or a complete deployment record-handling model.

Deployment Evidence Needed

For a digital workflow, pair GMC professional-duty evidence with configured record templates, authorship/time capture, amendment workflow, consent workflow, confidentiality route, training, clinical-safety case, and local medical leadership sign-off.