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Introduction
Quality in the medical record is crucial. The issues of legibility, attribution of each entry, date and time of each entry and content of each entry are key. This allows good patient care, good communication, and compliance with GMC requirements. In addition, a poor medical record hampers retrospective casenote review. The quality of casenotes reviewed in this study was assessed. Although difficult to measure, the advisor group consistently commented on the poor legibility of a large number of medical records. Table 1 shows that 59% of entries in the medical record did not have adequate contact details recorded and of these it was impossible to determine the grade of doctor who reviewed the patient in 43% of patients.
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