Requests for actual notes or original records

Report Writing

On some occasions you may receive a request for your clinical notes and records, either in photocopied or original form.

Where original notes are requested it is wise to make a copy for your purposes and to preserve the continuity of treatment. If you receive a request for original notes and have concerns about the provision of these notes, you should contact your professional association for advice.

There is occasional debate about the status of correspondence received by you from other practitioners who have treated the patient. Whilst it is true that the reports from specialists are the intellectual property of the writer, a court may compel disclosure of that information. Generally the courts will view this correspondence as forming part of your patient history if it contains material you have relied on to make clinical judgements.