What are medical records?
“Medical records” is a broad term, encompassing a range of data and information storage mediums containing patient information. Whether paper based or electronic, the term “medical records” applies to:
However, information exchanges (such as correspondence, email and file notes of discussions) between a medical practitioner and their medical indemnity insurer or solicitor should not be stored in the medical record. For this reason, it is recommended that you keep a separate medico-legal file in which to store these documents.
- clinical notes
- letters from other doctors and healthcare providers
- video footage
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