A patient presents with a sore wrist after a fall.

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 X, a 25-year-old fit and active man, was reviewed by his GP, Dr A, with a recurrence of lower back pain. He had noticed lumbar back pain intermittently throughout his 20s, but played a lot of sports to which he attributed his symptoms.

Ms Q, 58 years old, consulted Dr G, a gastroenterologist, with a history of dyspepsia, early satiety and altered bowel habit. Clinical examination, including digital rectal examination, was recorded as normal...

Patient B, a 70-year-old female, with a history of dementia, stroke and pneumonia, was admitted to the emergency room of a private hospital in a coma. She had advanced lung cancer and was well-known to the physician, Dr Y, who was called to see her.

A female patient at a medical centre consulted GP Dr F and was subsequently sent for further treatment at another department within the building.

Mrs Y, a 39-year-old chef, opted to M see consultant obstetrician Mr B for private antenatal care. It was her first pregnancy and other than a BMI of 30 she had no pre-existing medical problems.

A private neurosurgeon faces questions on consent, following a lumbar microdiscectomy sciatica and back pain

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.

Why are medicolegal issues important?

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.