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What are 3 things you should not add to a medical record?


The following is a list of items you should not include in the medical entry:
  • Financial or health insurance information,
  • Subjective opinions,
  • Speculations,
  • Blame of others or self-doubt,
  • Legal information such as narratives provided to your professional liability carrier or correspondence with your defense attorney,
Health and care records are confidential so you can only access someone else's records if you're authorised to do so. To access someone else's health records, you must: be acting on their behalf with their consent, or. have legal authority to make decisions on their behalf (power of attorney), or.