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:

  • clinical  notes
  • investigations
  • letters  from other doctors and healthcare providers
  • photographs
  • video footage
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.