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Medical records and the law

CPD Hours



Law, ethics and professional responsibilities
Managing people and resources
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The duty to maintain proper medical records is founded in the legal duty of care that all healthcare professionals owe their clients. If a patient suffers personal injury as a result of a healthcare practitioner’s insufficient or inaccurate record keeping, the healthcare practitioner could be sued for negligence or charged with a criminal offence. All those in professional practice are also required to meet record-keeping standards set by their professional regulatory bodies, which have the power to discipline those who fail to maintain proper medical records.

Complete and accurate medical records can, therefore, help healthcare practitioners to defend a criminal prosecution, civil claim, complaint, or disciplinary action. This module describes what medical records are and outlines the practical, ethical, and legal reasons for maintaining proper patient records. It aims to assist healthcare practitioners in improving their record keeping, benefiting patient care, and helping to prevent criminal, civil and/or disciplinary actions against them.

Learning Objective

At the end of this module participants will be able to:

  • Know what constitutes a proper medical record
  • Understand the legal and ethical bases for the duty to maintain proper medical records
  • Understand the practical basis for maintaining proper medical records
  • Know when and how to record complete and accurate medical records

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