Documentations and Dilemmas - an Assessment of Knowledge and Understanding of MBBS Interns Pertaining to Medical Records in Health Care.

Abstract

In both healthcare practice and judicial proceedings, the principle holds true: if it is not documented, it did not occur. With the rising incidence of litigations against medical professionals, the importance of accurate and comprehensive documentation cannot be overstated. Internship represents a critical phase of medical training, during which graduates engage in the documentation process under supervision, thereby developing essential skills in doctor–patient communication, continuous quality care, and professionalism. This cross-sectional observational study was conducted among MBBS interns to evaluate their knowledge and understanding of medical records. Findings revealed that interns demonstrated adequate comprehension of fundamental aspects, including the functioning of the Medical Records Department, objectives of record keeping, and qualities of effective documentation. However, notable gaps were identified in areas such as preservation and retrieval of records, duration of record retention, and their handling in legal contexts. Addressing these deficiencies through structured training programs, regular workshops, and early practical exposure with active intern participation can significantly enhance documentation practices. Strengthening these competencies will not only ensure the production of legible and reliable medical records but also provide interns with a valuable resource in legal proceedings—both as expert witnesses and in safeguarding against future litigations.