Chapter 9: Medical Records

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9 Terms

1

casualty MO

The ________ must ensure that all the registers are numbered and duly certified.

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2

Medical records

Comprise various documentary references of the care and treatment particulars provided to the patient.

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3

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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4

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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5

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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6

Medical records

It encompasses routinely the who, what, where and when of the patient care in the hospital.

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7

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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8

Non Medico Legal Cases

The IPD records have to be preserved for a minimum of 5 years.

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9

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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