Introduction

Medical record is an official document which contains detailed information recorded by a medical practitioner and paramedic that related to the diseases, health screening and treatment of a patient. It contains demographic data, history of illness, examination notes and treatment performed during the period of treatment. From the perspective of law, patient’s treatment information contained in the medical records are ‘CONFIDENTIAL’. Patient’s medical records are also a legal document to be tendered as evidence in a court of law.

The Role And The Importance Of The Legal Aspects In Medical Reports Are Categorized As Follow:

1. As A Document Of Evidence In The Court Of Law

In cases like murders and rapes, these particular crimes needs the medical practitioner or the forensic department are required to document/record meticulously regarding the findings based on the examination carried on the victim in the medical record which later, will be presented in a court of law. The findings are very crucial to support the investigation done by the police and the public prosecutor if a hearing is required. In order to give a statement, a medical officer must refer to the patient’s medical record as the main source of information in supporting the statement. The testimony will be in accordance with the information contained in the medical record as evidence in the court.

2. Medical Negligence Cases In Investigation Resources

On other legal perspective, errors or negligence by a medical practitioner who has treated patient(s) may be sued by claiming the damages of high value. A patient’s medical record is the only evidence that can defend the hospital. The copy of the medical report would be registered as evidence of that case and would be used by the plaintiff lawyer and the defendant to be debated during the hearing.

Complete information, its accuracy and the clearness in the medical record plays a significant key role in determining the decision of the court besides the witnesses.

3. Accident And Insurance Claims

Patients are entitled to claim insurance such as SOCSO or any other claims on the injury suffered from road accidents, sport injuries, industrial injuries or other incidents that allow patients to claim the compensation from the injuries incurred. For the fulfilment of the claim, a patient or beneficiary should obtain the medical report needed from the hospital in advance. Application for medical reports can be made through medical record department of the hospital where the patient was treated. The medical record contained with patient’s information including treatment histories will have an effect on the decision whether the patient is eligible to be compensated or otherwise.

4. Confirmation Of Documents Relating To Patients

Sick leave certificate and burial permit are examples of official documents that is issued by the hospital to the patient and the patient’s beneficiary. Medical records play an important role when requested by the patient’s employer requesting for verification of the sick leave certificate copy, the loss of a certificate or an investigation involving forgery of such certificates. In this case, patients’ medical records will be the only reference document for verification.