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Consent is an expression of autonomy and represents the right of a patient to make a decision in a medical matter concerning him. Consent is not just a procedural formality but also a legal requirement. The process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention. In India, the number of suits against doctors is increasing because of failure to take informed consent or inadequate consent from patients for various procedures. Any examination of a patient by the doctor without his consent amounts to assault (351IPC). Ignorance of laws is not a defense in negligence cases, so every practicing doctor should be aware of their responsibilities about consent in medical practice. Consent is not an option but a necessity in medical practice. Keywords: Consent; informed consent; autonomy

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A medical record is a confidential compilation of pertinent facts of an individual’s health history, including all past and present medical conditions, illnesses and treatment, with emphasis on the specific events affecting the patient during the current episode of care. The information documented in the health record is created by all healthcare professionals providing care and is used for continuity of care. It reflects and creates excellence in medical care and of Standards of Care. Documentation is legal protection for both patient and physician in the dispute over care. Failure to document important details can lead to adverse patient outcomes and malpractice suits. Keywords: Confidentiality, consent, documentation