Medical records are the documents that have all the details about the patient’s history, clinical findings, diagnostic test results, pre- and postoperative care, patient’s progress and medications administered. If documented correctly, the notes will support the clinician 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. They are usually required in cases of medical negligence under the Consumer Protection Act or in criminal courts. ²  

The legal system relies largely on documentary evidence in cases of medical negligence. Medical records are among the most important aspects which can practically decide the fate of almost every medicolegal battle. 1  Therefore, it is essential to ensure the integrity of medical records. Without proper medical records, a doctor may be 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 defence. ³

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.