Abstract

The recording and transmission of medical information poses many problems. The patient generally rarely sees his or her notes and possibly gives little thought to how or what is recorded, trusting that the doctor 'knows best' and will be noting, in a professional manner, that which will be useful for the diagnosis. In two cases presented, one of the patients sees her notes and is very upset by what she reads, the other requests that certain information be deleted from her case record. The actions of the doctors and patients were discussed in a preliminary conference at a recent postgraduate meeting. All the names in this Case conference have been changed.