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Changing Notes in Medical Records: A Proposal

Published online by Cambridge University Press:  01 January 2021

Susan Babin
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Extract

The hospital medical record is a multi-purpose document. It is the repository for all relevant (and sometimes not so relevant) medical information concerning the care and treatment of a patient during his or her stay in the hospital or visits to the Out-Patient Department or Emergency Ward. In addition, it serves as a form of communication among all past, present and future providers to help them provide medical care to the patient. With the gradual disappearance of solo practice as a major mode of health care delivery, and with the emergence of group practices, Health Maintenance Organizations, neighborhood health centers and hospital based primary care programs, this communicative function assumes even more importance. As a legal document, its existence is mandated by statute in many states, and it is frequently used as evidence in malpractice suits and other court proceedings. The medical record also serves as a research resource from which statistics and findings can be compiled to aid in a variety of studies and medical audits. Finally, it is an educational document which often is employed as a teaching tool in training students in the health field.

Type
Article
Information
Medicolegal News , Volume 6 , Issue 1 , Spring 1978 , pp. 4 - 8
Copyright
Copyright © American Society of Law, Medicine and Ethics 1978

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