Medical Records — Legal Perspectives

Abstract

Good documentation of medical diagnosis and treatment is not only a medical necessity, it is a legal one. Whether the physician is innocent or guilty of malpractice quickly becomes a side issue when it is discovered that he has tampered with the evidence, thereby attempting to perpetrate a fraud upon the court. And discovered it will be--the techniques are sophisticated and the motivation is high. Medical records are also important in workman's compensation cases, insurance claims, personal injury cases, and even in physician disciplinary hearings as well as their collection of bills. In creating and maintaining patient records, physicians and hospitals have several legal duties, including the duty to do so adequately, to safeguard the records' physical existence, and to prevent such use of the records as would violate the patient's right to confidentiality. Courts and legislatures are looking with increasing favor on the patient's interest in the content of his record, a phenomenon which is closely linked to the nationwide trend in favor of the patient's right to know and his right to determine his own physical destiny. For all these reasons, medical records no longer serve exclusively as the physician's private aid; medical records are increasingly becoming legal documents as well.