Medical records are documents that include complete details about the patient’s history, clinical findings, results of diagnostic tests, pre- and postoperative care, patient’s progress and medication/s administered. If written correctly, notes will support the doctor about the correctness of treatment.¹

Hospital medical records are a documentary evidence as per the Indian Evidence Act, 1872, as amended up to August 1, 1952 & 1961. Hence, they are usually required in cases of medical negligence under the Consumer Protection Act or in criminal courts.² 

The legal system relies mainly on documentary evidence in cases of medical negligence. Medical records are one of the most important aspect on which practically almost every medicolegal battle is won or lost.¹ Therefore, it is essential to ensure the integrity of medical records as without them you are deprived of any means to defend the allegation of negligence or professional misconduct. 

Good records mean good defence, poor records mean poor defence, no records mean no defence³

References

1. Bali A, Bali D, Iyer N, et al. Management of medical records: facts and figures for surgeons. J Maxillofac Oral Surg. 2011;10(3):199-202.
2. Singh S, Sinha US, Sharma NK.  Preservation of medical records - an essential part of health care delivery. Indian Internet Journal of Forensic Medicine & Toxicology. 2005;3(4).
3. Thomas J. Medical records and issues in negligence. Indian J Urol 2009;25(3):384-8.