Open AccessMEDICAL RECORD KEEPING; AN UPDATE
Author(s) -
Naveen Parkash Gupta,
R. K. Choubey
Publication year - 2019
Publication title -
international journal of medical and biomedical studies
Language(s) - English
Resource type - Journals
eISSN - 2589-8698
pISSN - 2589-868X
DOI - 10.32553/ijmbs.v3i7.379
Subject(s) - ticket , medical record , jurisdiction , medical profession , law , face (sociological concept) , medicine , medical emergency , political science , computer security , medical education , computer science , sociology , surgery , social science
Now a day’s Medical Profession not only deals with Medical affairs it involves various aspects of Legal Profession as well. Hence it should be re- coined as Medico Legal Profession. While providing any medical services if any issue arises then Doctors has to face the legal consequences and brought under the court jurisdiction for prosecution like other criminals.
The only thing which helps in front of court is the documents produced by the treating doctor, so keeping the Medical Records in meticulous manner, maintaining it & keeping it safe is very important.
So one should be very particular while recording the details & vitals in OPD Card, Bed Head ticket, Consent Form, Admission & Discharge Ticket of the patients. Doctors should be well aware of the things to be recorded into Medical Records, as well more aware about how to keep the records & to produce them when demanded in a Legitimate manor.
Keywords: Medical Records, Record Keeping, Medico legal, Guidelines, Legetimate