Chapter 9: Medical Records
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9 Terms
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casualty MO
The ________ must ensure that all the registers are numbered and duly certified.
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Medical records
Comprise various documentary references of the care and treatment particulars provided to the patient.
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professional secrecy
Information about the health of a patient given to the law courts is covered under privileged communication and the doctor is immune to the charges of breaking ________ under such circumstances.
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Medical records
It is the only valid data available regarding the patient treated by the health care professional, either as a general practitioner or as a hospital-based medical officer, irrespective of whether private or government origin.
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Medical records
It is mandatory that all healthcare professional should maintain the medical records of the patient examined/and treated by them on outpatient basis or as an inpatient case admitted in the hospital.
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Medical records
It encompasses routinely the who, what, where and when of the patient care in the hospital.
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Non Medico Legal Cases
The OPD records have to be preserved for a minimum of 3 years, when they can be destroyed.
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Non Medico Legal Cases
The IPD records have to be preserved for a minimum of 5 years.
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Medicolegal Cases
There is no specified time limit and hence they cannot be destroyed and must be made available as and when needed.
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