Documentation Practices

Accurate records are a professional requirement when pharmacy staff encounter possible FGM. Clear documentation supports accountability, meets safeguarding standards and helps protect patients. ^[1]

Essential Clinical Documentation

Pharmacy professionals must ensure their documentation includes:

• The exact wording of any disclosure and clear descriptions of observed behaviour and relevant circumstances. ^[2]
• Date, time and details of safeguarding steps taken, including police reference numbers where mandatory reporting applies. ^[3]
• Records of professional consultations, for example discussions with the designated safeguarding lead, referrals made, and guidance or decisions from external safeguarding agencies. ^[4]

Use clear, factual language and avoid subjective interpretation or assumptions. This preserves objectivity and professional accountability. ^[5]

Professional and Regulatory Compliance

Regulators require precise, objective records for safeguarding cases. Entries should record observations, patient statements and the actions taken so the record demonstrates compliance with statutory and professional obligations. ^[6]

Stores must keep FGM-related records secure, restricting access to authorised staff directly involved in care or safeguarding to maintain confidentiality and meet regulatory requirements. ^[7]