Good medical records: a guide for the foundation year doctor.
Maintaining good medical records is essential for providing safe and effective patient care. The General Medical Council (2006), in Good Medical Practice, suggests that doctors 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'. While good medical practice is necessary throughout one's medical career it is important to develop good qualities early in the training.
Singisetti
Kiran
K
University Hospital of North Tees, Stockton.
Staley
Helen
H
D004503:Education, Medical, Graduate; D006801:Humans; D008499:Medical Records / Q000592:standards*