EXPLORE!

What are the guidelines for preparation and maintenance of medical record?

  1260 Views

Dr KK Aggarwal & Advocate Ira Gupta    26 June 2019

Doctors should prepare and maintain medical records in the following manner:

  • Maintain different registers for specific purposes in their office or place of practice.
  • Maintain a separate register for the medical certificates issued, where in all details must be entered. Every certificate must include two identification marks, if not at least one identification mark of patient, his signature /left thumb impression should take in the space meant for that. Certificates are to be prepared in duplicate and one copy must be kept in the records as office copy which should contain the receipt signature of the patient or the legal representative.
  • All medical records including certificates must be prepared in a prescribed proforma.
  • All medical records should be written in a legible way or type written E.g.; writing diagnosis or prescription in capital letters is a better way. Scribbling must be avoided.
  • Medical records must be accurate, up to date, placed in order and complete in all respects. Incomplete or altered records create room for suspicion.
  • Any alterations in the medical record made must be initialled without obliterating the original entry. E.g. drawing a single line over the sentence / word.
  • The doctor must take some time / spend some time to prepare the patient’s details in documentary form or get them prepared by a trained competent assistant [in western countries trained medical clerks are used by the doctors].
  • Sincere efforts should be made to computerize the data, so that we can minimize the errors and the paper work can be brought down. (Facts of Medical Record Keeping - The Integral Part of Medical and Medico Legal Practice. *Gurudatta. S. Pawar, **Jayashree .G. Pawar)

To comment on this article,
create a free account.

Sign Up to instantly get access to 10000+ Articles & 1000+ Cases

Already registered?

Login Now

Most Popular Articles

News and Updates

eMediNexus provides latest updates on medical news, medical case studies from India. In-depth medical case studies and research designed for doctors and healthcare professionals.