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 in clinical negligence – a patient’s 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.

Dr Sarah Cornock

Disclaimer: All information in this edition of GP Registrar is correct at the time of publishing (Summer 2010)