Medical Record Legal Document

The medical record legal document is essentially used by hospitals for the dual purpose of keeping an account of the medical history of the patient as well as an exercise of the health care provider’s jurisdiction. The patient’s medical record is used by the health care facilities to treat patients according to the observations and medical history stated. It is important to note that this sort of document contains very personal information about the patient and hence, the hospital is obligated to ensure its confidentiality, failing which, the hospital can face a lawsuit. The medical record legal document also licenses the hospital to take the necessary course of action that it deems fit for the patient during treatment.

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

Sample Medical Record legal Document:

Medical Record Legal Document

Download Free Medical Record legal Document

Health Care Institution: Fortis International Hospital

Name of patient: Matthew Carlyle

Age: 45 years

Gender: male

Admitted for: A D/L Spine MRI

Date: 12.5.2011

Under the care of: Dr. Phillips

Previous MRI History: The patient has had a full body MRI from Fortis International Hospital on 5.4.2011

Medical History: The patient is suffering from bone cancer and is in the third stage of malignancy.

Exposure: Mr. Carlyle has been treated to Chemotherapy for the past 5 months. He has suffered with the side effects of hair loss and weight loss.

MRI observations: There has been severe damage to the vertebrae and clinical correlation is advised.

Medications Prescribed: Adrucil and Adriyamicin along with the previously prescribed medications apply.

Treatment to follow: Radiotherapy for the spine has been advised and it must be done at the earliest.


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