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

• New counter fraud code of practice - 8 May 2008
• Electronic records raise security risks - 10 January 2008
• Abbreviations cause confusion - 2 January 2008
• GMC publishes new guidance on treating under 18s - 23 October 2007
• New guidance to help prevent identification errors - 3 August 2007
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Case histories

• Delay in diagnosing appendicitis - 1 June 2007
• Communication error - 4 October 2005
• Incomplete notes on femur fracture - 1 October 2005
• Lack of notes - 1 March 2004
• Failure to diagnose meningitis - 1 October 2002
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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 should not see - 1 January 2002
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