Medical Records and Reports

The medical records and report are the vital source on running the medico-legal trial.

The medico-legal patient’s clinical record is a brief account of the personal and medical history of the patient, results of diagnostic tests, findings of medical examination, treatment and nursingcare, daily progress notes and advice on discharge.

Terms with the “Medical Records and Reports”

• The records are kept under safe custody of the nurse in each ward
• No individual sheet is separated from the complete record
• Records are kept in place, not accessible to patients and visitors
• No stranger is ever permitted to read the record
• Records are not handed over to legal advisors without the written permission of the administration
• All hospital personnel are legally & ethically obligated to keepin confidence all the information provided in the records
• All records are to be handled carefully, careless handling can destroy the records. All records are to be filed according to hospital custom, so that they can be traced easily. Records can be arranged Alphabetically, Numerically and Geographically
• All records are identified with the biodata of the patient such as name, age, ward, bed number, OP number, etc.,
• Medico legal records are never sent out of the hospital without the doctor’s permission. Reference is made by writing separate sheets and sending to the agency who requests for them Eg: Discharge summary