Instruments of medicine and law togetherThe medical records are considered a legal document and are subject to regulations and laws of the entity where they were generated. The information of an individual collected through the medical records, belongs to the same individual, however the property of the medical records varies from country to country and depends on the laws of which they were created. Regardless of the law of influence, usually the medical record is in custody of the medical practice that generated the file, and is used as a support in the patient care; it is their responsibility the good use of it, abiding by the norms, regulations and laws that apply.

Under this scheme it would seem that the patient is excluded from the information contained in his/her medical record, but this is because the medical record of an individual contains sensitive information, difficult to be interpreted. This is why it remains in custody of the medical professionals who are trained to interpret the correct information contained in them.

Today there has been a rise in complaints and lawsuits against health professionals, being the medical records of great importance, which is converted into a probative document in case of a request or complaint.

In such a way the medical record may be the salvation or perdition of a doctor against lawsuits. The medical record will reflect the performance of the entire staff that participated in the medical care of the patient and reflect their ability to solve problems, as well as their professional capacity.

That is why it is very important to have a well-integrated medical record, ordered, complete, legible, etc. that allows to evaluate in its full dimension the acting of the physician, facilitating the judicial proceedings, administrative or conciliation and arbitration. The medical record will provide essential elements to determine the performance of the health care provider involved.

Doctor and patient verifying documents