DOCUMENTATION AND AUTHENTICATION Introduction: The medical worker must pay care and attention to this aspect due its paramount importance. He must carefully document every procedure adopted towards the treatment of the patient in the specified medical records

THE MEDICAL RECORD 1. The physician or the institution he works in has to keep accurate medical records of the patients that contain the proper clinical results, adopted decisions and procedures, particularities of doses of medicine given to the patient and any other prescription or medications prescribed for the patient They should also contain all laboratory or other tests relating to the patient.

2. These medical records shall be kept in a safe place; and that no person other than those professionally connected with the patients care and treatment, are allowed to take a look into the medical record

3.The contents of the medical record are considered as a possession of the health-care facility where the patient is under treatment, however the patient has the right to look into and have a copy of his medical record

4.In case of referring the patient to another medical worker the former worker must provide the other one with all the necessary information about the patient condition.

5.the commonly recognized scientific and administrative principles must be followed when writing data and information in a document, and signature and date should be indorsed in every document relating to medical record

In case any change has happened,the date of change together with the signature must be written It is preferable that the change to any document be made in a separate page or sheet.

MEDICAL CERTIFICATES AND REPORTS Examples of these certificates: 1.death certificate 2.medical reports 3.sick leaves 4.patient attendance certificates

Therefore the medical worker has to be careful to make sure,before signing any document, that the data contained in the document is true.