Advice centre

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.

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.

Mrs G, 34, presented to the delivery suite at 12pm, 38 weeks into her first pregnancy. Her antenatal care had been uneventful apart from measuring slightly “large for dates”. She was found to have a longitudinal lie with a cephalic presentation, and was experiencing three contractions every ten minutes. The midwife examined her and found her to be 2cm dilated with a fully effaced cervix and “intact membranes”.

Needlestick injuries can be classified as any piercing wound caused by a hypodermic needle, or by other sharp instruments or objects such as scalpels, mounted needles, broken glassware, etc. This factsheet sets out the main concerns for healthcare professionals and what to do when needlestick injuries happen.

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.

An important starting point is your written report on the circumstances of the incident. This factsheet gives more information about writing this report.

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 Coroner’s inquest or a complaint to the GMC.

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.