New BASRaT Clinical Records Guidance Published
BASRaT has today released a fully updated Clinical Records Guidance for registrants.
This 2025 edition is a complete rewrite of the previous guidance, reflecting modern healthcare practice, digital record systems, and current legal and regulatory frameworks.
Clinical records are more than administrative documents, they are legal records and professional evidence of competent, safe, and ethical practice. They demonstrate clinical reasoning, informed consent, continuity of care, and adherence to BASRaT’s Standards of Ethical Conduct and Behaviour.
Key updates include:
Updated legal framework incorporating the UK GDPR, Data Protection Act 2018, and Mental Capacity Act 2005
New guidance on ICO registration, subject access requests, data breaches, deceased persons’ records, and the importance of records in clinical negligence.
Comprehensive coverage of informed consent, including Gillick competence and capacity considerations
Detailed sections on digital record systems, cloud storage, and AI-enabled scribing, reflecting advances in clinical technology and information governance
Refined record standards and retention guidance
The new guidance strengthens public protection and supports registrants in meeting their professional, legal, and ethical obligations through accurate, defensible clinical documentation.
Members can access and download the full document now via the Member Portal in the resources section under “member guidance documents”. Members are welcome to contact the Registrar, Ollie Coburn, with any questions.