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.

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.

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.

As an expert you should be aiming to produce a report which is free standing – from which the reader can glean the key issues in the case, understand the evidence available and reach a clear understanding of the range of expert opinion, without needing to look at any other document.