Consumer protection move in this medicolegal era has necessitated proper maintenance of ‘patients’ records which can become defense shields for the doctors in the court of law. Record can be defined as Documentary Evidence of any fact or an event. Not only outdoor-indoor papers but referral note, prescription, all certificates and all registers and even bills and receipts in hospital are also part of ‘record ’. Referral note should include date, time of issue of patient’s general conditions, cause and expected course of action. It’s wise to keep duplicate copy with patient’s signature. Prescriptions to the patients are an important document and need to be written carefully. Certifications to the patient have legal implications .also records are important guidelines for the clinical for the treatment of the patient. This article depicts all the details about medical documentation.