1. The primary purpose of medical records is to document all matters related to the health of a patient and to ensure continuity of care. Whilst you should write with a medical audience in mind you should be prepared to share and explain the content with patients.
2. Medical records should be clear, accurate and legible. Although abbreviations are used commonly, you should take care to use them only where their meaning is unambiguous and unlikely to cause offence.
3. Patients have the right, under the Data Protection Act, to ask for factual inaccuracies in the record to be rectified or deleted and such requests may become more common with online access. You should only comply with a request if you are satisfied that it is valid, although it is rare to delete an entry in its entirety. Any disputed entries can be annotated with the patient’s view.
4. Practitioners should be cautious when recording particularly sensitive information such as child protection issues. Only information related to the individual patient should be available, whilst protecting third parties’ confidentiality.
5. Doctors must ensure that information which may cause serious harm to the mental or physical health of the patient or third parties is limited from access, if possible.
Dr Pallavi Bradshaw is a medicolegal adviser at the Medical Protection Society