Study on Documentation of Medical Records

Documentation is the most essential part in Medical practice, it should be timely, accurate and complete. Whenever a case of medical negligence filed against a hospital, the only defence is medical record. Good records always provide a good defence. A cross sectional study was done on Medical record documentation at a rural medical college hospital, with an objective to appraise the importance of Medical record documentation with regard to various medico legal aspects. 100 case sheets were collected from the medical record department of the hospital and information from the case sheet was collected in to a data sheet and analysed for errors. None of the case sheet was free from documentation errors. We observed too many lacunae in the case sheets and explained how it leads to medico legal issues.