Medical Records- a Legal Perspective

Abstract

A medical record is a document containing chronologically written account of a patient’s examina-tion and treatment. A medical record apart from case sheet includes investigatory reports, investigatory samples, referral letter, discharge summary etc. Every registered medical practitioner is supposed to main-tain the proper medical report of his / her patient. The Indian government has laid down certain guidelines as to properly preserve the records. As a component of good medical practice it is necessary to maintain the medical records anticipating the litigation anytime. Key words: Medical records, Documentation, Electronic medical records, Medico legal report.