Good quality medical records are an essential component of safe and effective healthcare. Their main function is to facilitate continuity of care, but there are also many secondary uses they are put to. This booklet concentrates on the clinical and medicolegal aspects of keeping medical records, and on the related and important issues of confidentiality and security. It is divided into two parts.
Part 1 addresses the quality and accessibility of records, crucial factors in the safe and effective provision of healthcare services.
Part 2 deals with the legislative, regulatory and practical aspects of third-party disclosures and protecting patient records from loss, damage and unauthorised access.