Medical Records

Questions relating to medical records are a common reason for a call to MPS. In the last six months, GPs asking for advice on writing reports or providing access to records accounted for almost 20% of all calls.

But that is just the tip of the iceberg. 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 patients notes provide an objective record of the care you provided.

This issue of GP Registrar provides a reminder of some basic principles of writing good medical records. We also highlight some potential pitfalls and offer some guidance on avoiding them.