Legal Aspects of Medical Records

Abstract

A medical record is a confidential compilation of pertinent facts of an individual’s health history, including all past and present medical conditions, illnesses and treatment, with emphasis on the specific events affecting the patient during the current episode of care. The information documented in the health record is created by all healthcare professionals providing care and is used for continuity of care. It reflects and creates excellence in medical care and of Standards of Care. Documentation is legal protection for both patient and physician in the dispute over care. Failure to document important details can lead to adverse patient outcomes and malpractice suits. Keywords: Confidentiality, consent, documentation