Abstract:

The need of accurate documentation in safe practice cannot be overstated. The records kept by practicing doctors must be clear, accurate, and legible. The quality of clinical documentation contributes to the best possible care for the patient. Medical notes serve as a key conduit for communication between all individuals involved in the patients care, as well as with the patient and his or her family members. Medical records are becoming more and more important in medico legal disputes and litigation. Records may provide evidence for any claims that necessitate legal action, and this can happen months or even years after the incident, necessitating the requirement for accuracy. Data from clinical records can also be used for auditing and research. Medical records are also used to monitor hospital targets and performance. Deficient entries are caused by lack of knowledge, disinterest, habits, or a combination of these elements, putting both the patient and the doctor at risk. This may be due to the fact that education upon this issue is sporadic at best, and often non-existent.

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