1. The Medical Council of India guidelines address key issues around medical record keeping such as maintaining indoor records for 3 years, acknowledging and fulfilling record requests within 72 hours, and computerizing records for quick retrieval. 2. The guidelines recommend retaining inpatient records for 3 years, and outpatient records for 2 years, but records involved in medico-legal cases should be kept until the case is resolved. 3. Medical records are considered admissible and useful evidence in courts for issues like negligence cases, and hospitals have an obligation to produce accurate and complete records when summoned.

1. MEDICALCOUNCILOF INDIAGUIDELINESONMEDICAL
RECORDS
The issueofmedicalrecordkeepinghasbeenaddressedinthe MedicalCouncil ofIndia
Regulations2002guidelinesansweringmanyquestionsregardingmedicalrecords.The
importantissuesthathavebeenaddressedareasfollows:
1. Maintainindoorrecordsinastandardproformafor3yearsfromcommencementof
treatment(Section1.3.1andAppendix3).
2. Requestformedicalrecordsbypatientorauthorizedattendantshouldbeacknowledged
anddocumentsissuedwithin72hours(Section1.3.2).
3. Maintaina registerofcertificateswiththefulldetailsofmedicalcertificatesissuedwithat
leastoneidentificationmarkofthepatientandhissignature(Section1.3.3).
4. Effortsshouldbemade tocomputerizemedicalrecordsforquickretrieval(Section1.3.4).
5. TherearenodefiniteguidelinesinIndiaregardinghowlongtoretainmedicalrecords.
The hospitalsfollowtheirownpatternretainingthe recordsforvariedperiodsoftime.
UndertheprovisionsoftheLimitationAct1963andSection24AoftheConsumer
ProtectionAct1986,whichdictatesthetimewithinwhicha complainthastobefiled,itis
advisabletomaintainrecordsfor2yearsforoutpatientrecordsand3yearsforinpatient
andsurgicalcases.HowevertheprovisionsoftheConsumerProtectionActallowsfor
condoningthedelayinappropriatecases.Thismeans thattherecordsmaybeneeded
evenafter3years.Itisimportanttonotethatinpediatriccasesamedicalnegligencecase
can befiledbythe childafteraquiringtheage ofmajority.TheMedicalCouncilofIndia
guidelinesalsoinsistonpreservingtheinpatientrecordsinastandardproformafor3
yearsfromthecommencementoftreatment.Therecordsthatarethesubjectofmedico-
legalcasesshouldbemaintaineduntilthefinaldisposalofthecaseeventhoughonlya
complaintornoticeisreceived.ItisnecessarythattheGovernmentframesguidelinesfor
thedurationforwhichmedicalrecordsarepreservedbythehospitalssothathospitals
are protectedfromunnecessarylitigationinissuesofmedical records.
6. The provisionsofspecificActslikethePreConceptionPrenatalDiagnosticTestAct,1994
(PNDT),EnvironmentalProtectionAct,etc.necessitatepropermaintenanceofrecords

2. thathavetoberetainedforperiods asspecifiedintheAct.Section29ofthePNDTAct,
1994requiresthatallthedocumentsbe maintainedforaperiodof2yearsoruntilthe
disposaloftheproceedings.ThePNDTRules,1996requiresthatwhentherecords are
maintainedonacomputer,aprintedcopyoftherecordshouldbe preservedafter
authenticationbythepersonresponsibleforsuchrecord.
MedicalrecordsareacceptableasperSection3 oftheIndianEvidenceAct,1872amendedin1961
in a courtoflaw.Theseare consideredusefulevidence bythecourtsasitisacceptedthat
documentationoffactsduringthe course oftreatmentofa patientisgenuineandunbiased.
MedicalRecordsthatarewrittenafterthedischargeordeathofa patientdonothave anylegal
value.ErasingofentriesisnotpermittedandisquestionableinCourt.Intheeventofcorrection,
theentireline shouldbescoredandrewrittenwiththedateandtime.
Medicalrecordsareusuallysummonedinacourtoflawinthefollowingcases:
1. Criminalcasesforprovingthenature,timing,andgravityoftheinjuries.Itisconsidered
importantevidencetocorroboratethe natureoftheweaponusedandthecauseofdeath
2. RoadtrafficaccidentcasesundertheMACTActfordecidingontheamountof
compensation
3. LaborcourtsinrelationtotheWorkmen'sCompensationAct
4. Insuranceclaimstoprovethedurationofillnessandthe causeofdeath
5. Medicalnegligencecases-thesecanbeincriminalcourtswhenthechargeagainstthe
doctorisforcriminalnegligenceorundertheConsumerProtectionActfordeficiencyin
thedoctor'sorhospital'scare
It isusualtosummonadoctortoappearincourttotestifyandtobringallthemedical
documents.Whenthe courtissuessummonsformedicalrecords,it hastobehonoredand
respectedasitisaconstitutionalobligationtoassistintheadministrationofjustice.Therecords
can alsobeproducedincourtbythemedical recordsofficerofthe hospital.Ifthedoctoris
requiredtobepresentforgivingevidencebasedonthemedicalrecords,hehastobepresentin
thecourttogiveevidence.Thecourtmayrequirethesedocumentstobesubmittedforwhicha

3. recordisissuedbythe court.However,iftherecordsarerequiredforcontinuationofthemedical
treatmentofthepatient,copiescanbekeptbythehospital.
Therehavebeenmanyjudicial decisionspertainingtomedicalrecordsfromvariouscourtsin
Indiaandareviewofsome oftheimportantonesisgiveninthissection.
The NationalCommissionhadheldthattherewasnoquestionofnegligenceforfailuretosupply
themedicalrecordstopatientsunlessthereisalegaldutyonthehospitaltogivetherecords.The
allegedhospitalhadprovidedadetaileddischargesummarytothepatient.However,theBombay
HighCourtheldthatdoctorscannotclaimconfidentialitywhenthepatientorhisrelatives
demandmedicalrecords]WiththeenforcementoftheMCIRegulations,2002ithasbeenheld
withoutconfusionthatthepatienthasarighttoclaimmedical recordspertainingtohis
treatmentandthehospitalsareunderobligationtomaintainthemandprovidethemtothe
patientonrequest.
The hospitalanddoctorwereguiltyofdeficiencyinserviceascaserecordswerenotproduced
beforethecourttorefutetheallegationofa lackofstandardcare.[]Thepleaofdestroyingthe
casesheetasperthe generalpracticeofthehospitalsappearedtothecourtasanattemptto
suppresscertainfactsthatarelikelytoberevealedfromthecasesheet.Theoppositepartywas
foundnegligentasheshouldhaveretainedthecaserecordsuntilthedisposalofthecomplaint.[]
Notproducingmedicalrecordstothepatientpreventsthecomplainantfromseekinganexpert
opinion.Itisthedutyofthepersoninpossession ofthemedicalrecordstoproduceitinthecourt
andadverseinferencecouldbedrawnfornotproducingtherecords.[]TheStateCommission
heldthattherewasnegligenceasthecasesheetdidnotcontainaproperhistory,historyofprior
treatmentandinvestigations,andeventheconsentpaperswere missing.[