Deciding on a system for keeping medical records in a new rural health practice, or in an established practice seeking to update an obsolete system, may be confusing because of a multitude of vendors who claim to meet every need. Special circumstances set rural practices apart from other ambulatory care settings with regard to medical record needs. Practical consideration regarding filing systems, record content and format are offered in view of these special circumstances. Issues involving ownership of the record and access to confidential information are also explored.