Several judicial decisions pertaining to medical records have been reported from various courts in India. It is very important for the treating doctor to document the management of a patient under his care. Medical record keeping has evolved into a science of itself. This is the strongest way for the doctor to prove that the appropriate treatment was carried out. Moreover, it will also be of immense help in the scientific evaluation and review of patient management issues.
CONFIDENTIALITY Medical records can be used as a personal or impersonal document. Personal document - this information is confidential and should not be released without the consent of the patient except in some specific situations. Impersonal document – the record loses its identity as a personal document and patient permission is not required. These records could be used for research purposes. The patient can claim…
