Abstract

DOCUMENTATION OF MEDICAL RECORDS IN CONTEXT TO MEDICAL PRACTICE

Dr. Ravindra Anirudha Mirgane*

.

Abstract

Proper documentation of medical record promotes patients‘ and physicians‘ best interests for many reasons. Recording all relevant data of a patient‘s care helps physicians monitor what‘s been done, and curtails the risk of mistakes scrambling into the treatment process. Systematic medical records document basic facts about the patient‘s health care delivery system, including who did what, and what results occurred. Improper documentation on the other hand may invite medical litigation at any point of time. Sound record keeping also plays a role in quality assurance practices; hence medical litigation can be avoided.

Keywords: Medical record, medical litigation, Documentation.