Medical Records

Good record keeping is an integral part of good medical practice. In a busy GP practice, where patients can see a number of different health professionals or be referred to colleagues in secondary care, it is essential that records are accurate and up-to-date.

Additionally, if you are faced with any legal problem as a result of your practice – whether it is a complaint or a claim for negligence – a patient’s notes provide an objective record of the care you provided.

This issue of GP Trainee provides a reminder of some basic principles of writing good medical records – and the potential pitfalls to avoid.

Sarah Whitehouse
Editor