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.

Resources

Good Practice In Learning Disability Nursing November 2017 A document has been published to provide good practice guidance to support learning disability nursing to make a major...
Safeguarding Children In Whom Illness Is Fabricated Or Induced November 2017 A review of how Safeguarding Children in Whom Illness is Fabricated or Induced (2002) report makes a number of proposals...
Emergency Planning For NHS Organisations November 2017 Guidance on arrangements for service provision during a major incident has been published by the Department of Health. It...
Tackling Healthcare Associated Infections November 2017 Information on recent initiatives to tackle healthcare associated infections and details of new ideas to promote clean and...
Clean, Safe Care: Reducing Infections And Saving Lives November 2017 A document has been published which draws together recent initiatives to tackle healthcare associated infections and...
Seven Steps to Patient Safety in Mental Health November 2017 The National Patient Safety Agency (NPSA) has issued patient safety guidance for staff working in the area of mental health...
Meducation App November 2017 There are a ton of great medical education resources online but they can be scattered and hard to find. So Meducation does...
What Matters To Patients, Public And Staff October 2017 Research undertaken by the Department of Health has revealed what really matters to NHS staff and its users. Findings...
Helping People Who Are Unable To Make Some Decisions For Themselves October 2017 This booklet is one of a series of six on the Mental Capacity Act published by the Mental Capacity Implementation Programme...
Best Practice In Managing Risk October 2017 This framework is a guide for mental health professionals working with service users to assess risk. It underpins risk...
Search by Keyword