Abstract
Background: Medical record is a vital document, and the doctor/hospital has to maintain these records properly. Most medical negligence cases rely heavily on medical records to establish a case of negligence against the doctor. Poorly filled or incomplete medical records will usually work against the favour of the treating doctor. Methods: A total of 242 cases of medical negligence cases decided by the National Consumer Disputes Redressal Commission (NCDRC) from 2015 to 2019 (5 years) were analysed, and negligence/deficiency in service was proven in 126 cases of these lacunae in the medical records were found in 37 cases. Results: Some of the common mistakes were missed entry in the medical records (37%), deficient consent form (20%) and missing medical records (17%). Conclusion: Medical records play a vital role in medical negligence cases. Not maintaining proper medical records can leave the doctors/hospital vulnerable in liability cases.
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