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Medical records and reports
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
Advice articles
- New counter fraud code of practice
- Overseas treatment
- Electronic records raise security risks
- Abbreviations cause confusion
- GMC publishes new guidance on treating under 18s
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Case histories
- The hazards of foreign travel
- Delay in diagnosing appendicitis
- Communication error
- Incomplete notes on femur fracture
- Lack of notes
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