Facts of Medical Record Keeping - The Integral Part of Medical and Medico

Legal Practice.
*Gurudatta. S. Pawar, **Jayashree .G. Pawar
*Professor and Director P.G. Studies, Department of Forensic Medicine
**Associate Professor, Department of Pathology
J J M Medical College., Davangere - 577004, Karnataka
Abstract
Proper handling and maintenance of patient’s /deceased person’s medical records is an integral
part of medical and medico legal practice. This is the least bothered and most neglected section in
medical practice, especially in developing countries like India. Medical records have proven of
great help in medico legal matters and in cases of negligence suits filed against the medical
practitioner. Properly kept medical records can save the doctor from many unpleasant situations.
Indian law is not very clear about the facts of medical records. There are some guidelines issued by
recognised professional bodies regarding them. So it is must for a medical and medico legal
practitioners to know about the facts of medical and legal aspects of maintaining the patient’s
records for their own benefits, as ignorance is not always bliss.
Key words: Medical records, medical practitioner, medico legal expert, record keeping, patient

Introduction Reasons for knowing about them

All written material is documentary evidence India is slowly becoming a litigant society. The
in the eyes of courts of law. Preparation and doctors are being sued by the patients or by the
maintenance of these records is the integral part patient’s relatives on regular basis for trivial
of every profession. Same principle applies to the matters. In the present days of medical practice,
medical profession too. The technical, medical it is very important & essential to know about
and legal knowledge of preparing, keeping and this most neglected but important aspect of
maintaining medical records is an essential art medical profession. In many of the occasions the
to be known to every medical practitioner. allegations are either proved or disproved only
Medical records are documentary evidences, on the basis of the well kept or ill kept medical
which are of immense help not only in medico records. It is high time that the medical
legal cases but also in defending the doctor in professional should take a serious look at the
cases of negligence suits or allegations against facts of the physical and legal details of medical
him/her. There are many cases / instances which records. Just imagine the situation, you
are decided in favor of doctors only on the approaching a patient or a research project
grounds of well kept and well reproduced without any prior history or records, it is like few
records in consumer courts. Medical records have blind men describing an elephant. Medical
assumed more importance and significance records are not only of great help in medico-legal
because of application of Consumer Protection matters, but also they form an essential data of
Act to medical profession. However, doctors patient’s history, illness, treatment, prognosis etc.
because of their busy schedule, either don’t which are essential in research and advancement
maintain records or records are kept very brief, of medicine. They also act as statistical data used
incomplete, cryptic records which are of no use for formulating public health guidelines and
in court matters. 1 health policies of a nation.
Essential ingredients of a good medical record
Reprints Requests: Dr. Gurudatta. S. Pawar Medical records should be maintained serially
Professor and Director P.G. studies Department in a chronological order with dates and they
of Forensic Medicine, J J M Medical College,
Davangere -577004, Karnataka

Gurudatta. S. Pawar et al. Indian Journal of Forensic Medicine and Pathology. Aprl-June 2009; Vol. 2 No. 2 57
should preferably contain the following entries certificates must be prepared in a prescribed
in them. 2 performa. 3 All these documents should be
1. General particulars of the patient eg; Name, written in a legible way or type written Eg;
age, sex, address, emergency contact no, who writing diagnosis or prescription in capital letters
brought him / her [with details]. etc. is a better way. Scribbling must be avoided. The
medical records must be accurate, up to date,
2. Consent form duly filled and signed. placed in order and complete in all respects.
3. Dates and timings of examination / Incomplete or altered records create room for
admission and discharge – in patients. suspicion.
4. Dates and timings of all visits and Any alterations made must be initialed
consultation. without obliterating the original entry. Eg :
5. Details of the complaints – in a chronological drawing a single line over the sentence / word.4
order It just not sufficient to diagnose and treat a
patient properly .The doctor must take some time
6. Personal and past history. / spend some time to prepare the patient’s
7. Physical and laboratory / investigation details in documentary form or get them
findings (reports enclosed). prepared by a trained competent assistant [in
8. Treatment given / surgical procedures in western countries trained medical clerks are
detail.[immediate entry not later] used by the doctors]. India is a global hub for
computer and information technology. Medical
9. Day to day prognosis. fraternity must make use of the talents available
10. In case of death; precise cause of death, date in these fields. Where ever possible sincere
and time of death. efforts are to be made to computerize the data,
11. Details of consultation by other doctors and so that we can minimize the errors and the
their opinion. paper work can be brought down. Important
and wonderful part of these computerized data
12. In medico legal cases police need to be
is that they can be easily retrieved with a click
informed both at the time of admission as
of a button by the authorised user with basic
well at the time of discharge.
computer knowledge, as they are well protected
13. In patients; details of discharge, cause of by passwords.
discharge – cured / referred to other centre
Ideally if you are keeping the records with you
/discharge on request or against medical
then keep them under lock and key or in the
advice [DAMA]etc.
record room specifically meant for that , if such
14. Any other special findings which you feel facilities are available with the hospital or
noteworthy. institution. Make very sure that they are
How the records are to be prepared and accessible only to the authorized persons of the
maintained institution.
All medical practitioners must maintain Discussion
different registers for specific purposes in their Ownership of medical records
office or place of practice. Doctor must maintain Who owns these records?, Treating doctor or
a separate register for the medical certificates hospital or the patient or the legal representative
issued, where in all details must be entered. of the patient. This question is raised frequently
Every certificate must include two identification in various situations / forums by both doctors
marks ,if not at least one identification mark of and patients. Due to many reasons the custody
patient, his signature /left thumb impression of records varies from country to country. In
should taken in the space meant for that. some they are the property of the concerned
Certificates are to be prepared in duplicate and doctor who is treating the patient. In that case
one copy must be kept in the records as office the patient can have the copy of records
copy which should contain the receipt signature whenever the necessity arises. In India it is very
of the patient or the legal representative. The

58 Gurudatta. S. Pawar et al. Indian Journal of Forensic Medicine and Pathology. Aprl-June 2009; Vol. 2 No. 2
common practice that the patient keeps all the whichever is earlier ,even though it is so difficult
records with him or her especially in private to keep them for such along period. The need to
practice. In Government offered health services, maintain the records properly and produce them
the records are with the respective hospitals, only when asked by the courts of law itself is may
the treatment summary is given to the patient detour many doctors from entertaining medico
during discharge or need arises. India is legal cases in their day to day practice. There is
becoming the most preferred destination for an urgent need to do something about this matter
health tourism .The benefits of this influx are by the authorities.
being reaped by the mushrooming private or If any request is made for medical records
corporate hospitals. In most of these corporate either by patient/authorized attendant or legal
hospitals the patient’s records are with the authorities involved, the same may be duly
hospital and only the copies [may be in the form acknowledged and documents shall be issued
of treatment summary or photocopies of the with in 72 hrs. If the doctor refuses to give the
entire case file] are given to the patient. In many details / copies when requested by an authorized
parts of rural India or for that matter any person, he shall be charged for professional
developing countries the word of preparing or misconduct. Doctor will be held liable if he/she
maintaining medical records is almost unheard. discloses the records or the contents to any
Every one have developed and adopted their unauthorized person or without the consent of
own methods suitable for their setups. Likewise the patient. At present the medical records are
there are several methods which are adapted not covered under Right to Information act. No
presently due to lack of proper legal guidelines one can force a doctor to disclose the details of
in India with this respect. the patient other than the clauses given under
Legal status in India and abroad the doctrine of Privileged communications.
As such there are no legal guidelines for According to the Access to medical records act
keeping or maintaining the medical records in 1988, the patient’s records cannot be shown to
India. Law do not specify any period beyond the insurance agency or to the employer until
which the records can be destroyed. With so the patient has consented for its disclosure.7
many negligence cases which are being filed Patient’s records cannot be used for any purpose
against the doctors under consumer protection except for statistical data or for quality care
act, it has become essential to have some legal determination even without his/her consent. If
stipulations for preparation, maintenance and used with consent for presentations at
discarding the medical records. The consumer conferences, CME’s etc identity of the person
protection act advises to preserve the in patient should not be revealed either in text or in
records for five years and out patient records for photographs. A discharged patient should be
three years. Even though the records need not given discharge summary even when he is
be kept beyond 2 years, as the limitation period Discharged Against Medical Advice (DAMA)
for filing a case in consumer court is 2 years. and death summary should be issued to the next
Cases can be filed beyond 2 years period, of kin. Under Sec 104 of Cr.P.C. [power to
provided the delay can be explained to the impound document etc. produced] Courts have
satisfaction of the consumer court.5 power to summon any medical record.8
The Medical Council of India has given few U S congress passed (1996) the health
guidelines/ recommendations with reference to insurance portability and accountability act
the maintenance of the medical records. Doctor (HIPAA) and more stringent privacy rules went
must keep the medical records of an indoor in to effect in 2003. It included –
patient for at least period of 3 years from the date - National standards for medical records.
of commencement of treatment in the standard - Patient’s right to see his own medical records.
performa which has been laid down by the
Medical Council of India in 2002.6 Medico-legal - Right to know how his records are used and
records to be kept for at least period of 30 years disclosed.9
or up till the cases are decided in the court of law

Gurudatta. S. Pawar et al. Indian Journal of Forensic Medicine and Pathology. Aprl-June 2009; Vol. 2 No. 2 59
 There is an urgent need to bring an act to have records, which are fairly well protected for the
uniformity in preparing and maintaining the purpose of safety and easy retrieval. It will save
medical records in our country. Enacting and space and labour by eliminating paper based
implementation of such act will have positive records. Remember that honest and best
effects on the health care sector as well on the maintained records will save you from crisis and
national health policies and programmes. claims not just once but all the times.
Conclusion
References
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60 Gurudatta. S. Pawar et al. Indian Journal of Forensic Medicine and Pathology. Aprl-June 2009; Vol. 2 No. 2