Medical records should be maintained serially in a chronological order with dates and they should preferably contain the following entries in them.

1. General particulars of the patient e.g.; Name, age, sex, address, emergency contact no, who brought him / her [with details] etc.
2. Consent form duly filled and signed and thumb impression taken
3. Dates and timings of examination / admission and discharge – in patients.
4. Dates and timings of all visits and consultation.
5. Details of the complaints – in a chronological order
6. Personal and past history.
7. Physical and laboratory / investigation findings (reports enclosed).
8. Treatment given / surgical procedures in detail [immediate entry not later]
9. Day to day prognosis.
10. In case of death; precise cause of death, date and time of death.
11. Details of consultation by other doctors and their opinion.
12. In medico legal cases police need to be informed both at the time of admission as well at the time of discharge.
13. In patients; details of discharge, cause of discharge – cured / referred to other centre /discharge on request or against medical advice [DAMA] etc.
14. Any other special findings which you feel noteworthy