Clear documentation of every single transaction, process and action that takes place will allow you to have a clear reference point whenever anything is questioned. Medical Records are an important document meant basically for recording the treatment procedure meant for a patient. It is important both for the patient as well as for the doctor. It is important for doctors to realise that Medical Records have become the single most effective weapon in their hands to counter the claims of the patients, when they file a case for compensation. The law is very clear regarding the Medical Records and the value of it. The law requires proper maintenance of case sheets since they are the most important document that can be used in medico legal cases. In some cases these documents may serve as effective alibi for the patients too.
Medical Records can help prove the innocence of the doctors concerned and under medical ethics, the case report is supposed to be given to the patient on demand. Accusation of malpractices and unethical codes of conduct can be made against the concerned doctor / consultant if he / she fails to provide the patient with all the details and the case sheets of his admission, operation and the postoperative medication along with the dosage. It is an important aspect of the written evidence. It is strictly confidential document & should be produced as and when asked by the law. Medical records are medico-legal documents and a doctor can be cross-examined against the same. The patient also has the right to get his medical records and cannot be denied the same when he has paid the doctor / hospital for his treatment and hired their services. Not maintaining a proper record amounts to deficiency in service.
Medical Records are the backbone of any medical institution. With advancement in technology maintenance of medical records has become much easier and more efficient. Records and documents properly kept can become defence shields for the doctors / hospital in the court of law and is a good DMS Solution is highly recommended in hospital / clinics.
Contributed by Ashish Baby