Medical Legal Document

The medical legal document is a systematic way in which hospitals keep track of the patients and their medical history. It contains the specific medical information related to the patient. This is maintained and updated throughout the time period within which the patient is admitted. This contains observations, diagnoses, medication etc. pertaining to the patient and the treatment followed. The hospital is obligated to produce an accurate medical legal document. Any minor error can be life threatening and also become a legal problem for the hospital. Only certified professionals can compile the medical legal document and this also needs to follow standard format under the State Code of regulations.

You can Download the Free Medical Legal Document customize it according to your needs and Print. Medical Legal Document is either in MS Word, Excel or in PDF.

Sample Medical Legal Document:

Medical Legal Document

Download Free Medical Legal Document

The following Medical Legal Document has been created for Mr. Ryan Stiles under the care of St. Mary’s Health Care

Patient Code: T5667

Date: 3.4.2011

Admitted for: Fractured femur (left)

History of Patient:

  • The patient suffers from hyperglycemia and is being treated for it currently.
  • The patient had fractured his left femur previously as well.

Precautions: Surgery to be followed must keep in mind the above medical history of the patient.

Tests: X-Ray of left femur has been prescribed.

Discussion: Surgery has been ordered immediately.

Medications: To be prescribed after surgery.

Possible Complications: There might be infection and inflammation of the femur area. Ketoacidosis can occur as a result.

Surgery date: 4.4.2011

Mr. Stiles, hereby, gives St. Mary’s the full permission to follow the necessary treatment/surgery and will hold it liable for any adverse consequences including decease of the patient.


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