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.
Computers are now widely used in institution/hospitals for electronic patient records but still hard copy is required for following documents
- 1. Consent need to be on hard copy
- 2. Referral to doctor need hard copy.
- 3. Police case need hard copy.
- 4. Certificate of fitness should be on hard copy.
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