Advice centre

Mr M, a 44-year-old architect, attended his GP, Dr C, for a skin check. Dr C diagnosed a papilloma on his right chest wall as well as a seborrhoeic keratosis skin lesion of the upper left arm.

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

Providing access to medical records is essentially a confidentiality issue; therefore, the starting point is whether or not the patient has consented to disclosure. If not, access should be denied, unless there is some other clear justification for allowing access.

One incident can be investigated in a number of different ways – as a complaint, a clinical negligence claim, a criminal case, a disciplinary matter by your employer, a Procurator Fiscal’s FAI or a complaint to the GMC. An important starting point is your written report on the circumstances of the incident. This factsheet gives more information about writing this report.

Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

Providing access to medical records is essentially a confidentiality issue; therefore, the starting point is whether or not the patient has consented to disclosure. If not, access should be denied, unless there is some other clear justification for allowing access.

Confidentiality is at the centre of maintaining trust between patients and doctors. As a doctor, you have access to sensitive personal information about patients and you have a legal and ethical duty to keep this information confidential, unless the patient consents to the disclosure, disclosure is required by law or is necessary in the public interest. This factsheet sets out the basic principles of confidentiality.