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.

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”.

Needlestick injuries can be classified as any piercing wound caused by a hypodermic needle, or by other sharp instruments or objects such as scalpels, mounted needles, broken glassware, etc. This factsheet sets out the main concerns for healthcare professionals and what to do when needlestick injuries happen.

Forty-four-year-old Ms M presented to her GP with pain and swelling of her right knee. She had experienced similar symptoms three years earlier whilst pregnant but had not undergone any investigations at the time

Mr H, a 45-year-old solicitor and father of three, visited his GP Dr P with a persistent headache. He described two months of symptoms, occurring up to six times per week, mainly in the mornings and with associated nausea.

Mr M, a 44-year-old architect, attended his GP, Dr C, for a skin check. Dr C diagnosed a papilloma on his right chest wall as well as a seborrhoeic keratosis skin lesion of the upper left arm.

Miss A, a 40-year-old IT consultant, was talking to a colleague at work when she developed a headache, along with blurred vision and nausea.

Mr S was a 35-year-old taxi driver who was visiting his extended family abroad. While he was there he decided to have a routine health check in a private clinic. He told the doctor in the health clinic that he had noticed some rectal bleeding over the previous four months.

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.

An important starting point is your written report on the circumstances of the incident. This factsheet gives more information about writing this report.

One incident can be investigated in a number of different ways – as a complaint, a clinical negligence claim, a criminal case, a disciplinary matter by your employer, a Coroner’s inquest or a complaint to the GMC.

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.

Needlestick injuries can be classified as any piercing wound caused by a hypodermic needle, or by other sharp instruments or objects such as scalpels, mounted needles, broken glassware, etc. This factsheet sets out the main concerns for healthcare professionals and what to do when needlestick injuries happen.