The objects of medical records are:
(1) To serve as the basis for the patient’s care and for continuity in the evaluation of his treatment.
(2) To serve as documentation for reimbursement.
(3) To provide data for use in education and clinical research.
(4) To document communication between the doctor treating the patient and any other health care professional who contributes to the his care.
(5) To assist in protecting the legal interests of the patient, the hospital and the practitioner responsible for the patient.
(6) To follow-up the patients, evaluation of drug therapy and cost accounting. Medical records may be required in cases of professional negligence, for claims of third party payment under health and accident insurance, life insurance policies, policies for disability, accidental deaths, Workmen’s Compensation Act, traffic accidents, etc.
The minimum requirements of accurate medical records are:
(1) Name, father’s name, age, sex, occupation and address.
(2) Date and hour of visiting the doctor/nursing home/hospital.
(3) Evidence of informed consent.
(4) Brief history of present illness, relevant past history and family history.
(5) Findings of general physical and systemic examination.
(6) Diagnostic aids used and any reports received concerning the patient.
(7) Date and hour of consultation with details and opinion of consultant.
(8) Clinical impression with provisional and final diagnosis.
(9) Progress notes including clinical observations.
(10) Instructions given to the patient including diet.
(11) Complications, if any.
(12) Notations concerning lack of co-operation by the patient.
(13) Failure of him to follow advice or failure to keep appointments.
(14) Details of treatment including any• procedures/operations recommended or performed.
(15) In emergency cases, specific clinical data, and observations should be noted periodically.
(16) In in-patients, the condition at the time of discharge, i.e. whether cured or relieved of complaints or referred to any other hospital or discharged on request or absconded should be noted.
Regarding medical records, Council states that:
- A registered practitioner shall maintain a register of certificates giving full details of certificates issued with signature of patients and with at least one identification mark.
- To maintain medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of treatment.
- Routine case files should be preserved up to 6 years after completion of treatment and up to 3 years after death.
- Where there is a chance of litigation arising for purpose of negligence, file should be preserved for at least 25 years especially in case of minors.
- Medico legally important file should be preserved up to 10 years, after which they can be destroyed after making index and summary of the case.
- There are certain medical records of hospital which are of public interest and are transferred to public file library after 50 years for release to public and those involve confidentiality of the individuals are released only after 100 years.
The medical records must be accurate, appropriate, chronological, factual, relevant and complete. Nothing should be altered, deleted, substituted or added from the file, i.e. tampering should not be done. If tampering is done patient may be awarded large sums, even though there has been no negligence. The omission of essential details from the notes may cast a doubt on the truthfulness of the witness.
If a correction has to be made of a prior entry on the medical records, it should not be totally obliterated, but a single line should be drawn through the word to be changed, and the correct information should be written above with the date of the change and the person’s signature or legible initials. Further, an explanation as to why the medical records is being altered should be noted.
Good notes are of great value, not only when handing a patient over to another doctor, but also in meeting any criticism that may arise. If he refuses to accept the advice of his doctor, this fact should be filed in writing. When there is a conflict of evidence, the Court will attach importance to the notes written at the time. Good notes may be of the greatest importance in supporting the doctor’s evidence as against that of the plaintiff and his witnesses.
Patient has the right to know what is in his medical records and is entitled to a copy of his hospital file on discharge, by paying the cost of reproduction, but not to the original files. The next of kin can get the record in case of death. Hospital has the responsibility to supervise the maintenance of appropriate, accurate, timely and up-to-date medical records.
The rights of patients to have their hospital medical records regarded as confidential must be respected. If in the doctor’s judgement making the record available to the patient would be harmful or dangerous to him, or not in his best interest (professional or therapeutic discretion”), the hospital can avoid to issue the file to the patient.
The medical records of a patient should not be given to any person without the consent of the patient. The police do not have a right to demand medical records except when there is statutory provision for such requisitions.
The patient’s file cannot be used in educational or diagnostic conferences or clinics or for publications, without the his consent. Hospitals have right to use the medical records without the consent of him for statistical purposes and quality of care determinations.
In the absence of agreement to the contrary, X-ray plates are the property of the treating doctor as part of his case record. The patient buys the skill and treatment rather than the X-ray films.