Legal requirement of private practice medical records

The hospital medical record is a critical communication vehicle for the numerous health professionals who provide care to each patient. It is also an essential evidentiary tool in malpractice suits. Even though the medical record is not the sole information upon which the courts will rely in determining negligence liability, it can serve as an important chronology of care. Dietitians entering private practice, whether with a physician or not, should establish a system of record keeping. Although specific standards have not been set for private patient records, it is argued that records kept must meet many of the requisite guidelines for medical records in institutional settings. Additionally, the records must provide documentation that may be absent and difficult to obtain in the private setting. Discussed are legal issues surrounding patient records of the dietitian in private practice.