A good medical record has the following features:

It is easy to read, clear, concise, and accurate.

It is dated and timed properly.

It should have the following details: Patient name; Unique ID; Date.

It mentions the findings, investigations, results, and planned further interventions.

It should mention the drug treatment as well as administration of medications or blood products in detail.

Medical records should present a communication between the clinicians involved in the patient’s care. It should mention the management and progress of the patient so that any new clinician getting involved in the patient’s care can have affair idea on the treatment and progress. Patient contact should be appropriately recorded besides the clinical developments with respect to investigations done, action on results, future management plan, referral, and follow-up.