This document provides information on medical records, including their components, importance, confidentiality, and proper maintenance. A medical record contains a patient's key clinical data such as name, address, diagnosis, treatment notes, and test results. It is important for monitoring treatment, satisfying legal requirements, and having evidentiary value. Medical records should be maintained accurately and not altered improperly.

2. EAST ZONE MEDICO LEGAL SERVICES PVT.LTD

3. MEDICAL RECORD?
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A MEDICAL RECORD IS A COMPLETE RECORD OF A PATIENT’S
KEY CLINICAL DATA AND CONSISTS OF NAME OF
PATIENT, ADDRESS, AGE, SEX, OCCUPATION, DISEASE, MODES OF
DIAGNOSIS AND RECOMMENDATIONS MADE
THEREAFTER BY THE CONCERNED DOCTOR IN COURSE OF
UNDERGOING TREATMENT.
IT SETS UP A CRUCIAL ROAD MAP TO A PATIENT'S TREATMENT
REGIMEN AN ALSO HELPS THE DOCTOR PLAN OUT THE
REQUIRED INTERVENTION, PRECAUTIONS, AND PROGNOSIS OF
THE MEDICAL CASE.
COMPONENTS OF PATIENT’S MEDICAL RECORD
MEDICAL RECORDS INCLUDE THE FOLLOWING:
CHIEF SIGNS AND SYMPTOMS WITH WHICH THE PATIENT HAS
PRESENTED WITH.
HISTORY OF THE PRESENT ILLNESS
PAST MEDICAL HISTORY
FAMILY HISTORY
ALLERGIES
MEDICATION HISTORY
PHYSICAL EXAMINATION (E.G., VITAL SIGNS, MUSCLE POWER,
ORGAN SYSTEM EXAMINATIONS)
PROGRESS NOTES

4. TREATMENT NOTES
TEST RESULTS (E.G., IMAGING RESULTS, PATHOLOGY
RESULTS, SPECIALIZED TESTING)
IMPORTANCE OF MEDICAL RECORDS
USEFUL FOR MONITORING OF THE PATIENT'S TREATMENT
AND RESPONSE TO MEDICATION AND PROCEDURES.
A FAIR OVERVIEW OF THE CONDITION OF THE PATIENT FOR
THOSE CONSULTANTS WHO GET REFERRALS OR WHO
HAVE BEEN ATTENDING THE PATIENT AT THE REQUEST OF THE
FAMILY OR GENERAL PHYSICIAN
FOR THE NURSING STAFF TO CARRY OUT THE DAILY
INSTRUCTIONS REGARDING THE ADMINISTRATION OF
MEDICINES AS THEY GET THEIR INSTRUCTIONS AND DAILY
ORDERS REGARDING WHICH DRUGS ARE TO BE GIVEN
AND THE FREQUENCY OF EACH OF THEM
SATISFY LEGAL AND ETHICAL OBLIGATIONS: MEDICAL
REGULATORY AUTHORITY (COLLEGE), HOSPITAL, AND
LEGISLATIVE REQUIREMENTS FOR CLEAR AND LEGIBLE
RECORDS
IN THE ISSUE OF ALLEGED MEDICAL NEGLIGENCE, IT IS VERY
OFTEN THE MOST IMPORTANT EVIDENCE DECIDING
ON THE SENTENCING OR ACQUITTAL OF THE DOCTOR
WITH THE INCREASING USE OF MEDICAL INSURANCE FOR
TREATMENT, THE INSURANCE COMPANIES ALSO
REQUIRE PROPER RECORD-KEEPING TO PROVE THE PATIENT'S
DEMAND FOR MEDICAL EXPENSES. IMPROPER

5. RECORD KEEPING CAN RESULT IN DECLINING MEDICAL CLAIMS
IT HAS EVIDENTIARY VALUE IN THE COURT OF LAW AND CAN
BE EXHIBITED AND PROVED AS DOCUMENTARY
EVIDENCE AS PER SECTION(S) 61-63, INDIAN EVIDENCE ACT 1872
CONFIDENTIALITY OF MEDICAL RECORDS
IT IS A UNIVERSALLY ACCEPTED NOTION THAT THE
INFORMATION FOUND IN MEDICAL RECORDS IS CONFIDENTIAL.
BUT WHEN ANALYSING THE CONCEPT OF CONFIDENTIALITY,
THE QUESTION ARISES AS TO WHOM IS THE RECORD
CONFIDENTIAL & UNDER WHAT CIRCUMSTANCES IS IT
CONFIDENTIAL.
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INFORMATION IN THE MEDICAL RECORD IN BASICALLY OF TWO
TYPES: 1. IDENTIFICATION DATA: IT CONSISTS OF ENTRIES IN
THE RECORD WHICH DO NOT SPECIFICALLY RELATE TO THE
PATIENT CARE OR TREA TMENT IN THE HOSPITAL. E.G., NAME,
SEX, AGE, ETC. THESE ITEMS ARE OFTEN FOUND IN
THE ADMISSION RECORDS AND ARE GENERALLY NOT
CONSIDERED TO BE CONFIDENTIAL INFORMA TION. THIS
MEANS THAT UPON RECEIPT OF A LEGITIMATE REQUEST, IT IS
GENERALLY ACCEPTABLE TO RELEASE THE
INFORMATION WITHOUT THE PATIENT’S PERMISSION
2. CLINICAL DATA: THIS INCLUDES ALL ITEMS ENTERED IN THE
MEDICAL RECORD RELATING TO THE PATIENTS
DIAGNOSIS AND TREATM ENT. E.G.: REPORTS GENERATED BY
PHYSICIANS, NURSES, ALLIED HEALTH PERSONNEL

6. ETC.
CLINICAL INFORMATION IN MEDICAL RECORDS IS CONSIDERED
AS 'CONFIDENTIAL' BECAUSE IT IS HELD THAT THE
RELATIONSHIP BETWEEN PATIENT AND PHYSICIAN IS
'PRIVILEGED COMMUNICATION'.
WHO HAS ACCESS TO MEDICAL RECORDS?
MEDICAL RECORDS ARE THE PROPERTY OF THE HOSPITAL OR
PATIENT’S MEDICAL PRACTITIONER. HOWEVER, THE
FOLLOWING CAN HAVE ACCESS TO THE SAME:
PATIENT AND HIS LEGAL REPRESENTATIVE, AS LONG AS
PATIENT HAS SIGNED A RELEASE OF RECORDS TO
ACCOMPANY ANY REQUEST FROM THE LEGAL
REPRESENTATIVE
OTHER HEALTH CARE PROVIDERS, IF THEY ARE DIRECTLY
INVOLVED IN THE CARE AND TREATMENT OF THE
PATIENT
FOR RESEARCH PURPOSES, AS FAR AS THE IDENTITY OF THE
PATIENT IS NOT REVEALED AND THE CONFIDENTIALITY
IS MAINTAINED
MEDICAL RECORDS ARE USUALLY SUMMONED IN A COURT OF
LAW IN CERTAIN CASES LIKE-ROAD TRAFFIC
ACCIDENT, MEDICAL NEGLIGENCE, INSURANCE CLAIM ETC

7. EAST ZONE MEDICO LEGAL SERVICES PVT.LTD
RELEASE OF RECORDS
REQUEST FOR MEDICAL RECORDS BY PATIENT OR
AUTHORIZED ATTENDANT SHOULD BE ACKNOWLEDGED AND
DOCUMENTS SHOULD BE ISSUED WITHIN 72 HOURS OF RECEIPT
OF SUCH A REQUEST.
EFFORT SHOULD BE MADE TO COMPUTERIZE THE RECORDS
FOR QUICK RETRIEVAL.
CERTAIN DOCUMENTS MUST BE GIVEN TO THE PATIENT AS A
MATTER OF RIGHT. DISCHARGE SUMMARY, REFERRAL NOTES,

8. OR DEATH SUMMARY ARE IMPORTANT DOCUMENTS FOR THE
PATIENT. THEREFORE, THESE
DOCUMENTS MUST BE GIVEN WITHOUT ANY CHARGE. FAILURE
TO PROVIDE MEDICAL RECORDS TO PATIENTS ON
DEMAND WILL AMOUNT TO DEFICIENCY IN SERVICE
DOCTORS ARE NOT UNDER ANY OBLIGATION TO PRODUCE OR
SURRENDER THEIR MEDICAL RECORDS TO THE
POLICE IN THE ABSENCE OF VALID COURT WARRANT
A SUMMON TO PRODUCE CLINICAL RECORDS IS A FORM OF
COURT ORDER. FAILURE TO COMPLY TO SUCH A SUMMON IS
CONSIDERED AS 'CONTEMPT OF COURT' AND IS A PUNISHABLE
OFFENCE.
HOW LONG TO MAINTAIN THE RECORDS
UNDER THE PROVISIONS OF THE LIMITATION ACT, 1963 AND
SECTION 24-A OF THE CONSUMER PROTECTION
ACT 1986, IT IS ADVISABLE TO MAINTAIN MEDICAL RECORDS
FOR 2 YEARS FOR OUTPATIENT RECORDS AND 3
YEARS FOR INPATIENT AND SURGICAL CASES.
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HOWEVER, THE PROVISIONS OF THE CONSUMER PROTECTION
ACT ALLOWS FOR CONDONING THE DELAY IN
APPROPRIATE CASES. THIS MEANS THAT THE RECORDS MAY BE
NEEDED EVEN AFTER 3 YEARS.
MEDICAL COUNCIL OF INDIA GUIDELINES ALSO INSIST ON
PRESERVING THE INPATIENT RECORDS IN A STANDARD
PROFORMA FOR 3 YEARS FROM THE COMMENCEMENT OF

9. TREATMENT.
THE RECORDS THAT ARE THE SUBJECT OF MEDICO-LEGAL
CASES SHOULD BE MAINTAINED UNTIL THE FINAL
DISPOSAL OF THE CASE EVEN THOUGH ONLY A COMPLAINT OR
NOTICE IS RECEIVED
FOR MENTALLY RETARDED PATIENTS, THE DOCUMENTS
PERTAINING TO THE TREATMENT IMPARTED, MUST BE
MAINTAINED TILL PERPETUITY (FOREVER), TILL
HOSPITAL/INSTITUTION IS WORKING.
THE DOCUMENTATION FOR PERUSAL BY THE INCOME TAX
POINT OF VIEW MUST BE MAINTAINED FOR A PERIOD
OF 7 YEARS.
ALTERING MEDICAL RECORDS
PRESCRIPTION FOR DRUGS SHOULD BE LEGIBLE WITH THE
NAME OF THE PATIENT, DATE AND THE SIGNATURE OF
THE DOCTOR
AN UNDATED PRESCRIPTION IS ILLEGAL AND AGAINST SET
NORMS OF MEDICAL PRACTICE, CAN LAND A DOCTOR
IN TROUBLE IF THE PA TIENT MISUSES IT.
PROPER RECORDING OF NURSING CARE, LABORATORY DATA,
REPORTS OF DIAGNOSTIC EVALUATIONS, PHARMACY
RECORDS, AND BILLING PROCESSES.
NO OVERWRITING, WHILE WRITING THE MEDICAL NOTES. IN
CASE ANY AMENDMENTS HAVE TO BE MADE, STRIKE
THE WHOLE SENTENCE.

10. IF ANY CHANGES ARE MADE, SIGN AFTER MAKING THE SAME
AND PUT THE DATE AND TIME BELOW THE
SIGNATURE.
IN ELECTRONIC RECORD, AMEND BY STRIKING THROUGH
RATHER THAN DELETING AND OVERWRITING THE
ORIGINAL ENTRY.
DO NOT ALTER THE NOTES RETROSPECTIVELY. IF
SOMETHING WRITTEN WAS INACCURATE, MISLEADING OR
INCOMPLETE THEN INSERT AN ADDITIONAL NOTE AS A
CORRECTION THERETO.
ENTRIES IN A MEDICAL RECORD SHOULD BE MADE ON EVERY
LINE AS SKIPPING LINES LEAVES SPACE FOR
TAMPERING WITH THE RECORDS.
CORRECTION OF THE PERSONAL IDENTIFICATION DATA OF
THE PATIENT LIKE NAME, AGE, FATHER/HUSBAND
NAME, AND ADDRESS SHOULD ONLY BE MADE ON THE BASIS OF
AFFIDAVIT ATTESTED BY NOTARY OR 1ST CLASS
MAGISTRATE.
POINTS TO REMEMBER WHILE ISSUING MEDICAL
RECORDS/CERTIFICATES/DOCUMENTS
PRESCRIPTION
IT SHOULD BE PREFERABLY ON THE OPD SLIP OF THE
INSTITUTION OR ON THE LETTER PAD OF THE DOCTOR.
DRUG COMPANY OR CHEMIST PRESCRIPTION PAD SHOULD
NEVER BE USED.
MUST CONTAIN PATIENT’S NAME, AGE, SEX, ADDRESS AND

11. INSTITUTION/HOSPITAL NAME. PRESCRIBED DRUG
SHOULD BE PREFERABLY IN CAPITAL LETTER OR ELSE
CLEARLY VISIBLE.
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THE MEDICATION PRESCRIBED SHOULD CLEARLY MENTION
ITS STRENGTH, ITS DOSE FREQUENCY, DURATION IN
DAYS, AND TOTAL QUANTITY (NUMBER OF TABLETS AND
CAPSULES). BELOW THE MAIN DRUG- INSTRUCTIONS/
PRECAUTIONS AND CONTRAINDICATIONS SHOULD BE CLEARLY
MENTIONED.
ANY INVESTIGATION REQUIRED TO BE CONDUCTED, MUST BE
CLEARLY MENTIONED IN THE PRESCRIPTION. IF
PATIENT FAILS TO KEEP FOLLOW UPDATE AND IF THEN SOME
COMPLICATION OCCURS, THEN PATIENT IS ALSO
CONSIDERED NEGLIGENT (CONTRIBUTORY NEGLIGENCE)
REPORTS
ALL MEDICAL REPORTS SHOULD BE ISSUED BY A DULY
QUALIFIED PERSON UNDER HIS HAND AND SEAL.
BIOPSY REPORT SHOULD PREFERABLY BE ISSUED IN
DUPLICATE SO THAT THE REFERRING DOCTOR/HOSPITAL CAN
KEEP THE ORIGINAL COPY
IF THE PATHOLOGIST DOES NOT GIVE A DUPLICATE COPY THE
REFERRING DOCTOR SHOULD GET IT XEROXED AND
SHOULD BE HANDED OVER TO THE PATIENT
REFERRAL NOTES

12. THEY SHOULD INCLUDE THE DATE AND TIME OF ISSUE, THE
PATIENT'S GENERAL CONDITION, CAUSE OF
REFERENCE, THE TREATMENT GIVEN AND THE COURSE OF
ACTION TO BE TAKEN
ALWAYS KEEP THE CARBON COPY OF REFERRAL NOTE
ESPECIALLY IN CASE OF CRITICALLY ILL PATIENT, WITH THE
PATIENT’S SIGNATURE. THE FACT THAT THE PATIENT DID NOT
GO IMMEDIATELY ON REFERENCE AS ADVISED
COULD BE PROVED BY THE DUPLICATE COPY OF THE REFERRAL
NOTE KEPT BY THE DOCTOR. THIS COULD SAVE A DOCTOR WHO
COULD BE SUED FOR ALLEGED LATE REFERRAL AFTER THE
PATIENT'S CONDITION DETERIORATED
DISCHARGE CARD
IT IS IMPORTANT TO GIVE DUE IMPORTANCE TO MAKING A
PROPER DISCHARGE SUMMARY AS THIS IS THE
SUMMARY DOCUMENT WHICH REFLECTS THE TREA TMENT
RECEIVED BY THE PATIENT.
CONSULTANT IN-CHARGE SHOULD HIMSELF FILL OR
SUPERVISE THE DISCHARGE CARD
THE DISCHARGE SUMMARY SHOULD MIRROR THE CASE
NOTES OF THE PATIENT RECORDS WITH A BRIEF
SUMMARY, RELEVANT INVESTIGATIONS, OPERATIVE
PROCEDURES.
THE DATE OF ADMISSION, CONDITION OF THE PATIENT ON
THE ADMISSION, INVESTIGATION DONE, THE
TREATMENT GIVEN AND DETAIL ADVICE ON DISCHARGE
SHOULD BE WRITTEN ON DISCHARGE CARD.

13. IF ANY COMPLICATION IS EXPECTED AFTER DISCHARGE ASK
THE PATIENT TO REPORT IMMEDIATELY.
INSTRUCTIONS WHILE DISCHARGE MUST BE VERY CLEAR AND
ELABORATE.
DO NOT USE ABBREVIATIONS OR CODE MESSAGES IN THE
DISCHARGE SUMMARY/CARD.
IT IS ALSO IMPORTANT TO INCLUDE INSTRUCTIONS TO BE
FOLLOWED BY THE PATIENT AFTER DISCHARGE
INCLUDING DIETARY ADVICE AND DATE OF NEXT FOLLOW-UP.
THE DOCTOR CAN BE HELD NEGLIGENT IF PROPER
INSTRUCTIONS ARE NOT GIVEN REGARDING THE MEDICATIONS
TO BE TA KEN AFTER DISCHARGE, PHYSICAL CARE
THAT IS REQUIRED, AND THE NEED FOR URGENT REPORTING IF
AN UNTOWARD COMPLICATION HAPPENS BEFORE
THE ADVISED TIME OF REVIEW
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THE DISCHARGE CARD SHOULD BE SIGNED OR
COUNTERSIGNED BY THE CONSULTANT. A COPY OF THIS MUST
BE
PRESERVED IN THE CASE FILE FOR FUTURE USE IF REQUIRED
DISCREPANCIES IN THE SUMMARY GIVEN TO THE PATIENT
AND WHAT IS KEPT IN THE HOSPITAL RECORDS CAN
CAUSE SUSPICION ABOUT TAMPERING WITH THE MEDICAL
RECORDS. THESE DISCREPANCIES SHOULD BE AVOIDED
AT ALL COSTS AS THE BENEFIT OF THIS USUALLY GOES IN
FAVOUR OF THE PATIENT

14. IT IS NOT UNCOMMON TO HAVE PATIENTS WHO GETS
DISCHARGED AGAINST THE ADVICE OF THE DOCTOR. THESE
PATIENTS ARE ALSO ENTITLED TO HAVE A DISCHARGE
SUMMARY ABOUT THE COURSE OF TREATMENT. IT IS
IMPERATIVE TO RECORD THE FACT THAT THE DOCTOR HAS
ADVISED A COURSE OF ACTION WITH ALL ITS
IMPLICATIONS IF NOT FOLLOWED. THE FACT THAT THE
PATIENT HAS UNDERSTOOD THIS AND HAS REFUSED IT ON
HIS VOLITION SHOULD BE RECORDED. THIS SHOULD BE SIGNED
BY THE DOCTOR, PATIENT, OR RELATIVE AND DULY
WITNESSED. THIS DOCUMENT HAS TO BE RETAINED ALONG
WITH THE PATIENT RECORDS. IT WILL HELP THE
DOCTOR IN SITUATIONS WHERE THE PATIENT ALLEGES
NEGLIGENCE LATER.
MEDICAL CERTIFICATES
MEDICAL CERTIFICATE SHOULD BE ON INSTITUTION/DOCTOR
LETTER PAD.
DATE, TIME, AND PLACE SHOULD BE MENTIONED.
MEDICAL CERTIFICATES SHOULD BE ISSUED ONLY FOR
LEGITIMATE PURPOSE AND ONLY WHEN NECESSARY.
IT HAS TO BE TRUE AND CLEAR WITHOUT ANY AMBIGUITY.
THERE SHOULD BE AN IDENTIFICATION MARK OF THE
PATIENT, PREFERABLY A THUMB IMPRESSION.
PERIOD OF ILLNESS SHOULD BE CLEARLY MENTIONED.
DISCLOSURE OF THE DIAGNOSIS SHOULD BE ONLY AFTER THE
PATIENT’S EXPRESS CONSENT, UNLESS REQUIRED BY

15. THE LAW
DOCTOR SHOULD MAINTAIN THE DUPLICATE COPY OF EVERY
CERTIFICATE HE HAS ISSUED.
EMERGENCY DEPARTMENT REPORTS
A REPORT IS REQUIRED FOR ALL EMERGENCY DEPARTMENT
VISITS AND IS EXPECTED TO BE COMPLETED WITHIN 24
HOURS OF DISCHARGE/DISPOSITION FROM THE EMERGENCY
DEPARTMENT.
GUIDELINES FOR EMERGENCY DEPARTMENT REPORTS INCLUDE
THE FOLLOWING:
TIME AND MEANS OF ARRIVAL.
PERTINENT HISTORY OF THE ILLNESS OR INJURY, INCLUDING
PLACE OF OCCURRENCE AND PHYSICAL FINDINGS
INCLUDING THE PATIEN T’S VITAL SIGNS AND EMERGENCY
CARE GIVEN TO THE PATIENT PRIOR TO ARRIVAL, AND
THOSE CONDITIONS PRESENT ON ADMISSION.
CLINICAL OBSERVATIONS, INCLUDING RESULTS OF
TREATMENT
DIAGNOSTIC IMPRESSIONS
CONDITION OF THE PATIENT ON DISCHARGE OR TRANSFER
WHETHER THE PATIENT LEFT AGAINST MEDICAL
ADVICE(LAMA).
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THE CONCLUSIONS AT THE TERMINATION OF TREATMENT,
INCLUDING FINAL DISPOSITION, CONDITION, AND

16. INSTRUCTIONS FOR FOLLOW-UP CARE, TREATMENT AND
SERVICES.
PROGRESS NOTES
MUST BE DOCUMENTED/DICTATED ON A DAILY BASIS,
(PATIENT MUST BE SEEN BY THE PHYSICIAN AT LEAST ONCE
EVERY 24 HOURS AND RECORDED IN FORM OF THE PROGRESS
NOTE)
HANDWRITTEN NOTES MUST BE LEGIBLE
GIVE A PERTINENT CHRONOLOGICAL REPORT OF PATIENT’S
COURSE
REFLECT ANY CHANGE IN CONDITION
REFLECT THE RESULTS OF TREATMENT / RESPONSE TO
THERAPY
EXCEPTIONS MAY BE GIVEN TO AN OBSTETRICAL PATIENT
THAT HAS A DISCHARGE ORDER ENTERED FOR THE DAY
BEFORE.
OPERATIVE AND PROCEDURE REPORTS
NAME OF THE PROCEDURE/OPERATION
PREOPERATIVE/POSTOPERATIVE DIAGNOSIS
NAME OF PRIMARY SURGEON AND ANY ASSISTANTS
DETAILED ACCOUNT OF THE FINDINGS
COMPLICATIONS (IF APPLICABLE)
DESCRIPTION OF PROCEDURE(S) – TECHNICAL PROCEDURES
USED

17. SPECIMENS REMOVED (IF APPLICABLE)
ESTIMATED BLOOD LOSS
CONDITION AFTER SURGERY
INFORMED CONSENT
NAME/ AGE/SEX AND ADDRESS OF THE PATIENT SHOULD BE
PROVIDED
NAME OF THE PATIENT/GUARDIAN GIVING CONSENT IN THE
CASE OF THE MINOR
IN CASE OF GUARDIAN, THE SPACE SHOULD BE PROVIDED FOR
MENTIONING THE DETAILS OF THE GUARDIAN
INCLUDING THE RELATIONSHIP WITH THE PATIENT
NAME AND ADDRESS OF THE DOCTOR/HOSPITAL
REGISTRATION NUMBER, QUALIFICATION AND
SPECIALIZATION OF THE DOCTOR
DATE OF THE CONSENT GIVEN BY THE PATIENT
THE PRESENT CONDITION/DISORDER/DISEASE THAT THE
PATIENT IS SUFFERING FROM
NAME OF THE PROCEDURE(S) TO BE FOLLOWED
STATEMENT THAT THE RELEVANT SIDE-EFFECTS, RISKS AND
BENEFITS HAVE BEEN EXPLAINED
REASONABLE ALTERNATIVES TO THE PROPOSED
INTERVENTION AND SUPPORTING INFORMATION REGARDING
THOSE ALTERNATIVES
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18. CONSEQUENCES OF NON-TREATMENT INCLUDING THE
EFFECT ON THE PROGNOSIS AND THE MATERIAL RISKS
ASSOCIATED WITH NO TREATMENT
THE EXPECTED OUTCOME OF THE TREATMENT
ADMINISTERED
SHOULD STIPULATE ANY MEASURES/TREATMENT/SURGERY
THAT MAY HAVE TO BE ADMINISTERED ON AN
IMMEDIATE BASIS IN CASE THE TREATMENT/SURGERY FOR
WHICH THE CONSENT FORM IS BEING ISSUED IS
UNSUCCESSFUL
APPROXIMATE DURATION AND COST OF TREATMENT
STATEMENT OF THE PATIENT THAT HE GOT AN OPPORTUNITY
TO DECIDE AND TAKE A SECOND OPINION
STATEMENT OF THE PATIENT THAT THE PROCEDURE WAS
EXPLAINED TO THE PATIENT OR GUARDIAN AND HE/
SHE IN HIS/ HER CAPACITY/ COMPETENCE HAS VOLUN TARILY
CONSENTED FOR THE TREATMENT ON THE BASIS OF
ADEQUATE INFORMATION CONCERNING THE NATUR E OF THE
TREATMENT
SIGNED DECLARATION BY THE PATIENT THAT ALL THE
INFORMATION GIVEN BY THE PATIENT ARE TRUE TO THE
BEST HIS KNOWLEDGE AND HE WILL BE LIABLE FOR ANY
MISINFORMATION AND CONSEQUENCES ENSUING FROM
SUCH MISINFORMATION
SIGNATURE OF DOCTOR WHO EXPLAINED THE PROCEDURE
TO THE PATIENT OR GUARDIAN