Medical records-their medico-legal significance

This article discussed the physician's obligations in record-keeping and current judicial attitude towards the patient's medical record. Physicians are required, both medically and legally, to maintain a current, adequate record for each patient. This established the physician's continuity of care, but it also requires his vigilance and diligence through constant review and surveillance. In the past, the record was exclusively the property of the health care provider. Of late, jurisdictions are decreeing that the health care provider has an absolute right to possession and ownership of the original record only, and the right to the information in the record belongs absolutely to the patient. The physician is liable for the proper maintenance, custody, and storage of the record for the required statutory period. Although the patient can custimarily obtain his record by court order, the courts have also recognized the concept of professional discretion under which a physician may deny the patient access to his medical record if in the physician's judgment he believes it would be to the patient's detriment.