Patients Medical Record Discussion Question

I’m working on a health & medical discussion question and need an explanation and answer to help me learn.

A patient’s medical record is a collection of data recorded when a patient seeks medical treatment. The medical record is a legal document, and maybe subpoenaed as evidence in court.

If a healthcare practitioner isn’t keeping accurate patient records, are they guilty of malpractice? Please explain

What should be included in a patient’s medical record when care is given? Be specific

Medical records are the document that explains all detail about the patient’s history, clinical findings, diagnostic test results, pre and postoperative care, patient’s progress and medication. If written correctly, notes will support the doctor about the correctness of treatment. Inspite of knowing the importance of proper record keeping in India, it is still in the initial stages. Medical records are the one of the most important aspect on which practically almost every medico-legal battle is won or lost. This article discusses the various aspect of record maintenance.

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Record maintenance is the only way for the doctor to prove that the treatment was carried out properly. Medical records are often the only source of the truth. They are likely to be far more reliable than memory.

The management and preservation of the hospital records in Indian context present a very gloomy picture. Despite the intensive effort at national and international level, the fundamental health care needs of the population of the developing countries are still unmet. The lack of basic health data renders difficulties in formulating and applying a rational for the allocation of limited resources that are available for patient care and disease prevention.

It is recommended that more efforts should be made by the institutions/hospital managements, all clinicians and medical record officer to improve the standard of maintenance and preservation of medical records. In this article, we are discussing the various aspects of the medical record management.