Medical records are various documentary accounts of patients in relation to complaints, history, examination findings, results of diagnostic tests, therapeutic procedures recorded by a medical practitioner or medical record section of the hospital either public or government sector.
It is essential to maintain the medical records of all indoor and outdoor patients for the interest of adequate medical care as well as to provide evidence on being summoned by the court of law in certain civil suits and criminal matters.
Components for maintenance
- Particulars/ preliminary data of the patient (e.g. name, age, brought by whom)
- Date and time of arrival / examination
- Date and time of admission discharge
- Details of present/chief complaints
- Relevant personal/past/family history
- Details of physical examination and laboratory examinations
- Treatment prescribed
- Duly signed consent form for every procedure/operation
- Details of consultation/references/opinion of respective doctor
- In case of discharge-duly completed discharge summary, duly signed by patient/party specially in case of discharge against medical advice to be recorded.
- In case of death - cause, date and time of death
- Lastly, name and signature, address, council registration number of the doctor.
- Medical records and x-ray plates are the property of the hospital.
- Patient is usually entitled to a copy of investigation reports, treatment advised and the discharge summary. He/she can get a copy of hospital records, on payment of cost of reproduction.
- Medicolegal reports (e.g. injury report, rape report etc.) and autopsy report belongs to the requestor ( i.e the investigating officer).
- Medical records should not be given to third party, even under the provision of RTI Act.
- On summon by the court, the doctor/hospital have to produce it before the court without failure. This comes under privileged communication in medical practice.
Storage and disposal
All records should be kept under lock and key, confidentially, whether kept in digital or electronic form, is the total responsibility of the concern doctor/hospital record section. There is no time limit as to when the medicolegal records can be destroyed.
However, under the guidelines of directorate General of Health Services, the medical records should be kept available for the duration as:
- The OPD records-upto 5 years
- The IPD (including medicolegal case sheets) records-upto 10 years.