Examination of the medical records forms an essential part of the investigation of any case. While we may sometimes ask for the original notes, usually a complete set of photocopied notes should be sufficient.
- The notes should be in chronological order and preferably paginated.
- All records which are A4 size or less should be copied onto A4 paper. Please do not trim down the edges – leave A4 size.
- Items which are less than A4 size should be positioned so that they are copied centrally on the page and not in the top left hand corner.
- One item per page – whether a page of notes or for example a path report.
- Single-sided copying please.
- Ensure both sides of double sided documents are copied, but onto separate sheets.
- Particular attention should be paid to faint handwriting. Please ensure that it is legible and that the copying image is darkened if necessary.
- Coloured sheets do not copy well. Please take special care with these to ensure you have obtained the best copy possible.
- Letters entitled ‘Private and Confidential’ from a consultant to the GP form part of the medical records and, as such, should be included in the copy set.
- A ‘complete copy set of notes’ means clinical case sheets, all results, referrals and general correspondence. If computer records are part of the set we need, they do not copy well and a computer printout would be helpful.
- When supplying us with a copy set of notes please keep them together with a clip.
- Please do not hole punch or staple or fold the copy notes.
- Please send the copied notes to us in a strong A4 envelope.