Chapter: 4.4 Types of records

Types of records

Case papers can be indoor, or outdoor. Outdoor case papers are usually left with the patients.

Indoor case papers are important documents. Here it is necessary to record detail history and complaints and examination findings of the patient. Some important points which should never be forgotten are the history of allergies; previous surgeries and that of on-going medications.

1 Operation notes

Form an important part of any case records. If post operative complications occur, court will always look at the correctness of steps having been taken during the surgery.

Sometimes, properly written notes of difficult surgeries can protect the surgeon in case of post operative complications. Again, an informed consent form has to be filled in and maintained. It should, however, be remembered that even the most comprehensive consent form does not give a license to a doctor to be negligent in his patient care.

Consent form is only a proof of patient’s agreeing to undergo the legitimate and proper treatment.

2 Prescriptions

A prescription should have a name of the patient and should be dated. It should be legible and properly signed. Before writing a prescription a doctor should confirm that the patient is already not allergic to the same medicine, the side effects and interactions with the other drug. In case of the female patient possibility of conception. Undated prescriptions can be misused and can get the doctor in trouble in a medico-legal situation.