Mrs A, was admitted for a triple coronary artery bypass graft operation for her NSTEMI. She had a past medical history of thoracic (T9-T10) spinal fusion for fractures secondary to a viral illness more than 20 years ago.

Record keeping plays a major role in the development of this case, which sees GP Dr O receive a clinical negligence claim following the insertion of an IUCD.

Julie Baylis, Case Manager at Medical Protection, looks at a recent High Court case and how it underlined the importance of good quality medical records.

GP Dr D and consultant gastroenterologist Dr B face a claim after an abandoned colonoscopy fails to pick up the required diagnosis. Medical Protection handles the case.

Mr S was a 60-year-old lorry driver. He was overweight and smoked, and couldn’t walk far because he suffered with pain in his calves.

From 25 May 2018, the EU General Data Protection Regulation (GDPR) (1) will come into force and will have a direct effect in every EU country.

Mr E, a 50-year-old accountant, was playing squash with a colleague after work and hurt his left ankle. He couldn’t keep playing but he was able to walk, so he went home. The next day his ankle became quite swollen, so Mr E kept it on ice and took some ibuprofen...

Mrs M was a 64-year-old care assistant in a retirement home. She visited her GP with a two-month history of blood in her stools, altered bowel habit, and intermittent lower abdominal discomfort.

This Essential Guide was produced as a resource for Medical Protection members in the UK. It is intended as general guidance only.

General Practice remains one of the most popular of all the specialties, with about a quarter of all candidates ranking it as their top choice, and more than half likely to apply for it as one of their choices for specialty training.

Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal. The approach to consent in Northern Ireland is currently governed by common law.

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.

You owe a duty of confidentiality to all your patients, past or present, even if they are adults who lack capacity. You may be asked to provide information from the medical records of patients who are incapable of giving consent, are aged under 18, or have died. This factsheet gives you further information about dealing with these circumstances.

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.

Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.

Respect for patients autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.

Doctors may, on occasion, receive a request from a patient’s employer for a medical report to be delivered directly to the HR department, without the patient seeing it. However, before any medical report can be provided, you must be satisfied that the patient has given valid consent to the release of the information. This factsheet looks at the issues surrounding medical reports for employers and other organisations, and offers advice to doctors who are asked to write reports.

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.