GPs & primary care professionals

Medical records and reports

Patient's records are among the most basic of clinical tools, involved in almost every consultation. This section offers guidance about the content, disclosure and retention of clinical records and includes guidance on writing medical and medico-legal reports.

Questions and answers

• Missing consent form - 22 October 2002
• Should I delete an entry from the records? - 1 May 2000

Advice articles

• Child protection documents – storage and disclosure - 19 March 2010
• Security of electronic records - 25 June 2009
• New cremation rules come into force - 22 January 2009
• Controlled drugs: strengthening the audit trail - 2 January 2009
• Delayed diagnosis in primary care - 1 August 2008
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Case histories

• To whom it may concern - 1 May 2009
• Granting a deathbed wish - 1 May 2009
• The hazards of foreign travel - 1 December 2007
• Delay in diagnosing appendicitis - 1 June 2007
• Communication error - 4 October 2005
• View all (16)

Advice calls

• Ring of confidence - 1 December 2007
• Chaperones - 1 December 2007
• Observing parental reprimand - 1 May 2005
• Retention of medical records - 19 March 2004
• Fees for notes - 1 April 2003
• View all (9)