Medicolegal Aspects

Keeping clear, accurate and contemporaneous patient records is a prime responsibility of all medical practitioners. Patient records make effective healthcare possible. They document treatment and outcomes, and in a medico-legal context, they serve to demonstrate professional integrity and justify what you did. It is little wonder then, that when patients complain or make a claim, your medical records - how accurate and sensitive they are, and how you kept them - can come under intense scrutiny. Make them robust enough to withstand that scrutiny, particularly as patients now have rights to access paper and electronic records.

History:  As it applies to the condition and relevant past history including concurrent illnesses, medications and allergies.

Examination of the patient: include positive and relevant negative findings, and record all pertinent observations and measurements (e.g. pulse, temperature, BP).

Diagnosis: record this clearly and concisely, justifying how the conclusion was reached and recording any uncertainties or differentials.

Investigations: including lab results and imaging such as X-rays or scans.

Management: record drugs prescribed and administered with dosage, and other treatments, such as physiotherapy.

Follow up and referral: include details of follow-up tests, future appointments and referrals.

Patient information: include details of discussions regarding risk-benefit, treatment plan, prognosis and potential complications.

Consent: record consent given, ensuring that it take into account the above.

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