GPs & primary care professionals

Medical records and reports

Patient's records are among the most basic of clinical tools, involved in almost every consultation. This section offers guidance about the content, disclosure and retention of clinical records and includes guidance on writing medical and medico-legal reports.

Questions and answers

• Missing consent form - 22 October 2002
• Should I delete an entry from the records? - 1 May 2000

Advice articles

• Security of electronic records - 25 June 2009
• New cremation rules come into force - 22 January 2009
• Controlled drugs: strengthening the audit trail - 2 January 2009
• The dangers of abbreviations - 1 June 2008
• New counter fraud code of practice - 8 May 2008
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Case histories

• The hazards of foreign travel - 1 December 2007
• Delay in diagnosing appendicitis - 1 June 2007
• Communication error - 4 October 2005
• Incomplete notes on femur fracture - 1 October 2005
• Lack of notes - 1 March 2004
• View all (14)

Advice calls

• Ring of confidence - 1 December 2007
• Chaperones - 1 December 2007
• Observing parental reprimand - 1 May 2005
• Retention of medical records - 19 March 2004
• Fees for notes - 1 April 2003
• View all (9)