What information should a medical record contain?

A medical record provided by a doctor to a patient should contain the following information¹, 2010):

• Name and registration number of treating doctor
• Name, demographic details and contact number of patient
• Relevant clinical history, assessment and reassessment findings, nursing notes, diagnosis
• Investigation reports
• Details of medical treatment, invasive procedures, surgery and other care provided
• Applicable consents
• Discharge summary
• Cause-of-death certificate & Death Summary (where applicable)

1. Annexure 7, Clinical Establishments Act ,2010 (Standards for Hospital Level 1A & 1B[↩]