Good medical records – whether electronic or handwritten – are essential for the continuity of care of your patients. Adequate medical records enable you or somebody else to reconstruct the essential parts of each patient contact without reference to memory. They should therefore be comprehensive enough to allow a colleague to carry on where you left off.

Certain circumstances can mean you are obliged to disclose information about a patient, even if you do not have their consent; under other circumstances, disclosure may be justifiable. This factsheet gives you further information about these circumstances.

You owe a duty of confidentiality to all your patients, past or present, even if they are adults who lack capacity. You may be asked to provide information from the medical records of patients who are incapable of giving consent, are aged under 16, or have died. This factsheet gives you further information about dealing with these circumstances.

If a death occurs in a violent or unnatural manner, in custody, or suddenly but without certain cause, the Procurator Fiscal has a duty to inquire into the death. This factsheet sets out the role of the Procurator Fiscal, the reporting process and what will happen once you have reported a death to the Procurator Fiscal.

Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.

Respect for patients autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.

The Care Act (2014) sets out the framework for local authorities to use (alongside health and social services)to protect adults considered at risk from abuse or neglect.

Making and using audio and visual recordings of patients can benefit medical training, research and treatment. However, it poses risks for doctors regarding consent and confidentiality. In addition, all recordings from which living individuals can be identified constitute personal data and are subject to the provisions of the Data Protection Act.

If a death occurs in a violent or unnatural manner, in custody, or suddenly but without certain cause, a coroner has a duty to enquire into the death. This factsheet sets out the role of a coroner, the reporting process and what will happen once you have reported a death to the coroner.

You owe a duty of confidentiality to all your patients, past or present, even if they are adults who lack capacity. You may be asked to provide information from the medical records of patients who are incapable of giving consent, are aged under 18, or have died. This factsheet gives you further information about dealing with these circumstances.

The Immigration Act 2014 and recently updated regulations on charging overseas visitors for NHS care have led to changes in the way overseas visitors and migrants are charged for NHS care. Although mainly an administrative issue, there are key points that need to be understood by clinicians to ensure that patients are treated appropriately and their information is safeguarded.

Under the Misuse of Drugs Act (1971) and the Misuse of Drugs Regulations (2001), GPs have a responsibility for controlled drugs (CDs) within their practice. This factsheet highlights what you should be aware of when carrying, storing and recording controlled drugs.

Doctors may, on occasion, receive a request from a patient’s employer for a medical report to be delivered directly to the HR department, without the patient seeing it. However, before any medical report can be provided, you must be satisfied that the patient has given valid consent to the release of the information. This factsheet looks at the issues surrounding medical reports for employers and other organisations, and offers advice to doctors who are asked to write reports.

A doctor’s primary concern is to do their best for their patients; this includes giving advice and treatment, and arranging investigations in accordance with the current evidence base and the patient’s best interests.

The GMC states that “Whether or not you have vulnerable children or young people as patients, you should consider their needs and welfare and offer them help if you think their rights have been abused or denied.” Surgery consultations, home visits, accident and emergency admissions and contact with other professionals who work with children help to build up a picture of a child’s situation.

Medication errors account for approximately 20% of all clinical negligence claims against doctors in both primary and secondary care. The costs associated with adverse events and inappropriate prescribing in the UK has been estimated at more than £750 million per year. This factsheet gives advice about avoiding prescribing errors.

The GMC states that “Whether or not you have vulnerable children or young people as patients, you should consider their needs and welfare and offer them help if you think their rights have been abused or denied.” Surgery consultations, home visits, accident and emergency admissions and contact with other professionals who work with children help to build up a picture of a child’s situation.

Mrs G, 34, presented to the delivery suite at 12pm, 38 weeks into her first pregnancy. Her antenatal care had been uneventful apart from measuring slightly “large for dates”. She was found to have a longitudinal lie with a cephalic presentation, and was experiencing three contractions every ten minutes. The midwife examined her and found her to be 2cm dilated with a fully effaced cervix and “intact membranes”.

Respect for patients’ autonomy is expressed in consent law; to impose care or treatment on people without respecting their wishes and right to self-determination is not only unethical, but illegal.

Making and using audio and visual recordings of patients can benefit medical training, research and treatment. However, it poses risks for doctors regarding consent and confidentiality. In addition, all recordings from which living individuals can be identified constitute personal data and are subject to the provisions of the Data Protection Act.