In-patient as well as out-patient medical
records generated in the hospital, in its own interest as well as for the
patient are required to be stored for stipulated time depending on the
relevance of the record.
Good practices required in managing medical records.
Why are medical records so
important?
Medical records constitute a range of medical
care documents, which include patient’s history, diagnostic investigations,
consent documents, operative notes, nurses’ daily notes, intake / output sheet,
treatment sheets, etc. Managing these records systematically is really
important, as these records are the only way for the doctor to prove that the
treatment was carried out properly. These records become the sole and critical
evidence for the treating doctors to defend themselves from false claims.
How Are Medical Records
Stored?
Today at most hospitals, medical records are
paper based and are stored manually in designated areas in the hospitals – some
have a dedicated medical records room and officers looking after them. However,
with increasing volumes of patients over the years, the physical records occupy
more space and its more time consuming and difficult to retrieve the patient
record. The paper based records are also prone to damage by weather, rodents,
dust, etc.
Classification of Medical
Records
There are two ways in which medical records can
be relevantly classified: the extent to which they can be shared and the
contents of the records.
The Extent to Which Records
Can be Shared:
Must be given to the patient- certain records,
viz. discharge summary, referral notes, etc., have to be shared with all
patients including those who are discharged against medical advice irrespective
if the bill payment has been made.
Can be given to the patient after a formal
application- records such as, indoor papers, operative notes, investigations,
etc., requires a formal application from the patient. The copies of these
records given to the patient are generally attested as true copies by the
hospital.
Given only with direction of the court - some
OPD and IPD records, especially those of medico-legal cases cannot be given to
the patient without the direction of the Court.
On the other hand, medical records can be
distinguished as per the constituent documents and each of them have its own
significance, for example – discharge notes, are considered as a critical proof
with respect to the in-hospital treatment provided to the patient, irrespective
of the fact that the patient has been discharged with / against the advice of
the doctor.
Preservation Period, Legal
Aspect
There has been ambiguity with respect to clear
regulations on how long a medical record must be preserved. Most hospitals
follow their own set of policies in retaining records as per the relevance. The
limitation period for filing a case paper is up to three years under the
Limitation Act 1963 (two years under the Consumer Protection Act 1986). Nonetheless,
the limitation period starts only after the patient becomes aware of the effect
of the alleged negligence by the doctor.
The Maharashtra Government has issued a
resolution (ref GR No. JJH-29 66/ 49733) which says that OPD paper should be
kept for three years, indoor case papers for a period of five years and in case
of a medico-legal case, 30 years. Usually medical records are summoned in a
court of law in:
- Medico
legal cases: where often the medical records are referred to establish
medical history / treatment given, especially important in road traffic
accidents, medical negligence, etc.
- Insurance
cases: where the insurance company wants to review the medical records
verify the claim
- Workmen’s
compensation cases: In cases where an injury occurs to a workman out of
and in the course of employment.
- Criminal
cases – to prove the nature, timing and gravity of injuries.
MCI Guidelines
The Medical Council of India, has issued the
(Professional Conduct, Etiquette and Ethics) Regulations, 2002, which mentions
the following on Maintenance of Medical Records (Section 1.3)
- Every
physician shall maintain the medical records pertaining to his / her
indoor patients for a period of three years from the date of commencement
of the treatment in a standard proforma laid down by the Medical Council
of India (Section 1.3.1 and Appendix 3).
- If
any request is made for medical records either by the patients /
authorised attendant or legal authorities involved, the same may be duly
acknowledged and documents shall be issued within the period of 72 hours
(Section 1.3.2)
- A
registered medical practitioner shall maintain a Register of Medical
Certificates giving full details of certificates issued. When issuing a
medical certificate he / she shall always enter the identification marks
of the patient and keep a copy of the certificate. He / She shall not omit
to record the signature and/or thumb mark, address and at least one
identification mark of the patient on the medical certificates or report.
The medical certificate shall be prepared as in Appendix 2. (Section 1.3.3
and Appendix 2).
- Efforts
shall be made to computerise medical records for quick retrieval. (Section
1.3.4)
