| Abstrakt: |
Managing your medical notes is essential to avoid medico-legal pitfalls. Good medical records are, of course, an essential part of patient care. The General Medical Committee (GMC) guidance Good Medical Practice states that one should keep clear, accurate, legible and contemporaneous patient records which report the relevant clinical findings, the decisions made, the information given to patients and any drugs or other treatment prescribed. As healthcare relies increasingly on electronic records, the GMC adds that National Health Service professionals should have reliable and rapid access 24 hours a day to the relevant personal information necessary to support their care. Good medical notes provide an objective record of a patient's care and are essential in responding to a complaint or claim. Even if the general practitioner has done nothing wrong in terms of clinical care, unless medical records prove this, it is extremely hard to defend the claim. |
