Medical Records Management

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)