Hospital doctors & specialists

Medical records and reports

Patients' 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

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
• The dangers of abbreviations - 1 June 2008
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Case histories

• To whom it may concern - 1 May 2009
• Granting a deathbed wish - 1 May 2009
• Delay in diagnosing appendicitis - 1 June 2007
• Communication error - 4 October 2005
• Incomplete notes on femur fracture - 1 October 2005
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Advice calls

• Ring of confidence - 1 December 2007
• Chaperones - 1 December 2007
• Retention of medical records - 19 March 2004
• Fees for notes - 1 April 2003
• Comments the patient shouldn't see - 1 January 2002
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