If continuity of care for patients is to be assured, it is vital to keep good medical records, whether they are handwritten or electronic. Health professionals and others are able to use adequate medical records to reconstruct the essential parts of each patient contact, without the need to refer to memory. When medical notes are sufficiently comprehensive, it is easier for health professionals to carry on where a colleague left off. Keeping clear, accurate and contemporaneous patient records is a prime responsibility of all medical practitioners.
They document treatment and outcomes, and in a medico-legal context, they serve to demonstrate professional integrity. The necessity for permanency of care for the patient is the main reason to maintain medical records. Health professionals also find good medical records vital for defending a complaint or clinical negligence claim, given the…
