MPS advises GP Registrars on Good Medical Records

December 2016

General Practitioners

Country of origin: UK

The Medical Protection Society has published the latest issue of GP Registrar, its periodical containing topical medicolegal advice for GP registrars.

The issue focuses on keeping good medical records and provides a reminder of some of the basic principles, highlighting potential pitfalls and giving guidance on avoiding them.

Questions relating to medical records are a common reason for members to call MPS. In the last six months, GPs asking for advice on writing reports or providing access to records accounted for almost 20% of all calls.

Dr Alison Metcalfe, senior medicolegal adviser at MPS, said: ?Clear and comprehensive medical records are an essential part of good medical practice. Medical notes should allow a health professional to reconstruct a previous consultation with the patient.

In a busy GP surgery, where patients can see a number of different health professionals or be referred to colleagues in secondary care, it is essential that records are accurate and up-to-date.

Good medical notes are indispensable in responding to complaints and claims and are increasingly valuable in improving standards of patient care.?

The edition of GP Registrar is available online.

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