ABSTRACT
Effective clinical note keeping will never be a substitute for clinical competence and all the other qualities that make a complete doctor. Outpatient letters from hospital doctors to general practitioner's (GPs) are usually written at the end of each clinic session. A family complained to the chief executive that their mother had to wait in casualty for eight hours without seeing a doctor. Most doctors hand over details of sick patients to on-call colleagues when they go off duty. A more complete typed document, the discharge summary, summarising the patient’s stay in hospital and aftercare arrangements, is usually written by a more senior doctor and sent to the GP some days or weeks later. A doctor on a vocational training scheme worked as gynaecology senior house officer for three months. GMC guidelines suggest doctors print their name, specialty, grade and bleep number after their signatures.
