Importance of Medical Records | Legal Case Influence

BusinessLegal

  • Author Santosh Guptha
  • Published March 21, 2018
  • Word count 494

What are Records?

The records tend to tell or mention any sort of data or information in a document format. These are posed in a systematic manner; due to they being systematic, the records are easy to read and configure at the time of need. Medical records also have a systematic order and also hold relevant information, required at the time of need. They are of vital importance as it is but also give a proper detail of the illness and possible history.

What do these records contain?

The Medical records contain all the necessary information about an individual. It usually has the name of the person, the age bracket, the gender, the illness, the diagnosis, the treatments and the preventions to follow. These play a major role when the patients visit the doctor for a follow up, as all the data is already present in a written format.

Importance in Legal Cases:

While dealing with medical cases, the records hold vital value and because of that the information is very sensitive.The medical record contains valuable information about a patient's medical history and individual clinical interactions. A properly made and maintained record is a legal document used in lawsuits if need be.

One cannot undermine the relationship between the doctors and any fretful party because a patient will always need counselling for better understanding of the disease. But if the concerned party is using the sensitive information in an inappropriate manner, then that is worrisome.

Such is its importance that in case of any mishap, the patient can use said document to take legal action against the doctor for any wrongful approach. Doctors also require particular medical results for further study of disease. Such studies are conducted on a large scale but discretion is kept in mind. But if the records are being used in a negative manner, the person using them should be cautious. One cannot undermine the relationship between the doctors and any fretful party because a patient will always need counselling for better understanding of the disease. But if the concerned party is using the sensitive information in an inappropriate manner, then that is worrisome.

When working towards better health care, this point needs to be given more awareness so that patients know any wrong-doing will not be tolerated.A patient as well as doctor may derive the respective file/information in case of necessity as legal evidence.Law requires proper maintenance of case sheets because these are the single most important document that can be used in medico legal cases.

Summary points:

• Medical records are utmost important in every way.

• Records showcase the treatment required and medical history.

• They can be used in a legal manner if need be.

• They word as a case file for the respective patient.

• Maintenance of records is vital.

Conclusively, it is important for both patients and doctors to be made aware of such incidents so that any need for harsh can be eradicated.

Dr Santosh kumar guptha provides Medical coding classes for medical coders and billers with HIPAA training

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