9.1: Medical Records

• Medical records — comprise various documentary references of the care and treatment particulars provided to the patient.

• It is the only valid data available regarding the patient treated by the health care professional, either as a general practitioner or as a hospital-based medical officer, irrespective of whether private or government origin.

• It is mandatory that all healthcare professional should maintain the medical records of the patient examined/and treated by them on outpatient basis or as an inpatient case admitted in the hospital.

• It encompasses routinely the who, what, where and when of the patient care in the hospital.

Contents of Medical Records

The medical records should contain the following:

• Particulars of the patient, e.g. name, age, sex, address brought by (name of the person who has brought him to the hospital), referred by, etc.

• Date and time of arrival and examination in hospital.

• Date and time of admission and discharge from hospital.

• The present complaints by the patient at the time of arrival.

• Relevant past history.

• Relevant family history.

• Relevant personal history.

• Details of physical examination done by the physician and the findings.

• Laboratory examinations and other investigations advised for and their reports, e.g. blood sugar, blood urea, X-ray, etc.

• Treatment given.

• Duly completed consent form for each and every procedure/s and operation/is performed.

• Prognosis chart.

• Details on cross consultations/references to other specialist doctor/s and his/their opinions and reports.

• In case of discharge from hospital — the condition at the time of discharge.

• Maintain a discharge card with discharge summary providing brief information on admission particulars, investigations done, treatment given and follow-up advice given at the time of discharge to the patient.

• If the discharge is against medical advice (AMA), then record accordingly and take signatures of the patient and/or his/her guardian/relative with whom the patient leaves the hospital.

• Copy of Police Intimation Letter with all details of information given to the police in every medicolegal cases.

• In the case of death, note down the cause, date and time of death.

• Name and signature, address, medical council registration number/license of doctor.

In Medical Cases

In addition to routine contents mentioned above, certain additional precautionary measures are to be observed in all medical cases, and they are:

• The casualty MO must ensure that all the registers are numbered and duly certified.

• All pages of the record should be serially numbered.

• On all pages, laboratory reports and X-ray plates, the word MLC should be marked. It should be so even on requisition for laboratory investigations and X-ray.

• All the entries should be correct and in detail and in sequential order.

• Abbreviations should be avoided.

• All corrections done should be initiated.

• All medicolegal documents should be prepared in duplicate.

• All communications with police should be in writing only, and a copy of all such correspondence should be attached to the case papers/file.

• There is no time limit as to when the medicolegal case records can be destroyed by the hospital.

• All records should be kept under lock and key.

• All entries in hospital papers should carry the signature and name of the doctor concerned.

Property Rights of Medical Records

• The medical records and also X-ray plates are property of the hospital.

• The patient buys the expertise and the treatment rather than the hospital records and the X-ray films.

• All records are kept in the hospital for the benefit of the patient, doctor and the hospital.

Patient’s Rights

• The patient is given a copy of the investigation reports, treatment advised and the discharge summary.

• The patient has the right to know the details in his/her records and is entitled to get a copy of his/her hospital record on discharge, on payment of cost of reproduction.

• In case of death of the patient, the next of kin can have the hospital records.

• If, in the opinion of the doctor, making the records available to the patient would be harmful or dangerous to the patient; he/ she may avoid issuing the records to the patient.

Medical Records in Court

• When the hospital/doctor has been summoned by the court, requesting for production of the case records, they have to be produced before the court without failure.

• The court may require the medical records in all alleged criminal cases such as assault, burns, criminal abortion, dowry deaths, injury, murder, poisoning, rape, suicide, and vehicle accidents, etc. In some of the civil cases also medical records may have to be procured by the court.

• Information about the health of a patient given to the law courts is covered underprivileged communication, and the doctor is immune to the charges of breaking professional secrecy under such circumstances.

• Hospitals should arrange for photocopying every page of the case file prior to taking them to the court, as the court usually retains the records.

• Whenever the court needs the document to be retained, the hospital doctor should demand a receipt from the court specifying clearly the total number of pages withheld by the court.

Submission of Records to Government and Other Agencies

• On several occasions’ government and other agencies such as LIC place a request to supply the information about a patient treated in the hospital.

• As per law, they are not entitled to this information without the written consent of the patient, and hence the hospital should not comply with such requests.

• Information about name, age, sex, date of admission and date of discharge, etc. can be given as these are not confidential.

Storage and Disposal of Medical Records

• Non Medico Legal Cases (Non-MLC)

  • The OPD records have to be preserved for a minimum of 3 years, when they can be destroyed.

  • The IPD records have to be preserved for a minimum of 5 years.

• Medicolegal Cases (MLC)

  • There is no specified time limit, and hence they cannot be destroyed and must be made available as and when needed.