Medical Record Department

2. MEDICAL RECORDS: MEANING AND ESSENTIALS
 The WHO guidelines on Medical Records Practice define a medical record as ‘a collection of data
compiled on a patient to assist in the clinical care of present and future illness’
 The medical records are not a mere repository of information, but it is a continuing record that acts as a
source of future communication among the healthcare providers
 medical records, have health information of patients/ individuals ranging from personal, professional,
demographic, familial, financial, clinical, and genetic

3. AS PER THE WHO
GUIDELINES, A MEDICAL RECORD SHOULD BE
 able to identify the patient,
 legible and able to be understood by anyone likely to use it,
 accurate, logical and concise in its organisation,
 consistent in layout and the size of papers used in it,
 able to identify the people who are contributing to the record so that they may be asked for further
information if necessary,
 promptly retrievable when required.

4. USES OF MEDICAL RECORDS
 It is used for better patient care,
 better management of health care system,
 health surveillance,
 medical and biomedical research,
 reimbursement of medical cost under Government and Private insurance schemes,
 evidence in medico-legal cases,
 predict the outbreak of epidemics,
 predictive and precision medicine,
 the process of clinical creativity,
 conditions of social life, and a reliable source for historians.

5. THE PRACTICE OF MEDICAL RECORD-KEEPING: THE RELEVANCE AND
ITS EVOLUTION
 On tracing the history of medical records, it can be found that patients records were invented thousands
of years ago by the father of medicine, Hippocrates.
 He had shown keen interest in preparing notes about his patient’s appearance, social situation,
symptoms, etc. to decide the treatment and he also recommended storing these documents for future
reference.

6.  The early modern medical practitioners who worked outside the hospital system maintained diaries,
registers or testimonials to record the patient-related information though it was not properly structured
and standardized.
 With the introduction of computer technologies during the 20th century, there occurred a transition
from paper records to Electronic Medical Records (EMR)
 21st century marks the beginning of Personal Health Records (PHR)25 in various jurisdictions like US, UK,
Canada, India, etc.

7. INDIAN SCENARIO OF MEDICAL RECORD-KEEPING
 medical record-keeping became an obligation only after 2002 when the Medical Council of India issued
the Ethical Guidelines
 Clinical Establishments Act, 2010, also made it mandatory for all clinical establishments registered under
the Act to keep medical records of patients in electronic format.
 Government of India has been introducing many services such as tele- consultations, e-hospital, m-
raktkosh, etc. since 2015 under the ‘Digital India Programme’.
 India launched the ‘National Digital Health Mission (NDHM)’ on August 15, 2020,which offers services for
Electronic Medical Records (EMR) and Personal Health Records

8.  Electronic Medical Records provide the details of the patients' medical treatment history and other
health information and are usually maintained by the health care facility.
 Personal Health Records system is introduced to ensure patients’ control over their health information
and it will be controlled by the account holders.

9. MEDICAL RECORD DEPARTMENT & ITS FUNCTIONS
1. Maintenance of Inpatient medical Record i.e. Case of the patients since 2005 till date.
2. Forwarding the Birth and Death Reports of this hospital to the District/Zone Sub- Registrar. The
patients/relatives may obtained the Birth or Death Certificates from the said office within one year
after that it may be obtained from their head office of Registrar Births and Deaths,
3. Maintaining Medico Legal Registers since 2005 till date.
4. Receipt of Summons from the Court of law and deputing the records clerks or the doctors as the
case may be to attend the court with the requisite records.
5. Medico Legal Correspondence with the police authorities regarding issue of Discharge Summaries,
Injury/ medical reports and the MLC Reports.

10. 6. Correspondence regarding patients of this hospital i.e. regarding
1. Issue of letter to District/Zone Sub- Registrar for any correction/modification in the birth & death reports sent
to NDMC, if required by the inpatients/relatives in their particulars on the basis of written application,
submitted by the patients or their relatives.
2. Preparing Monthly and yearly Hospital Statistical data of this hospital.
3. Coding (ICD-10 i.e. International Classification of Diseases, Tenth Revision) on the case sheets for generating
Diagnostic data of the inpatients of this hospital.
4. Answering the Parliament Questions for the information available in this Department and Sending
various diagnostic data reports to various health agencies as and when required.
5. Answering the RTI Queries for the information available in this Department
6. Any other work assigned by the Head of this Institution.

11. ALTERING MEDICAL RECORD
 1. While writing the medical notes, as far as possible do not overwrite. If the change is needed, strike the
whole sentence. Do not leave ambiguity. Make a habit of signing if change is made. Preferably put the
date and time below the signature. Attempting to obliterate the erroneous entry by applying the
whitener or scratching through the entry in such a way that the person cannot determine what was
written originally written raises the suspicion of someone looking for negligent or inappropriate care
 2. Do not alter the notes retrospectively. If something written was inaccurate, misleading or incomplete
then insert an additional note as a correction.

12.  3. Entries in a medical record should be made on every line. Skipping lines leave the room for tampering
with the records.
 4. Amend on electric record by striking through rather than deleting and overwriting the original entry.
After inserting the new note, add date, time and doctor name.
5.Correction of the personal identification data of the patient like name, age, father/husband name, and
address should only be made on the basis of affidavit attested by notary or 1st class magistrate.

13. HOW LONG TO MAINTAIN THE RECORDS
 1. Ideally records of adult patient are maintained for 3 year.
 2. 21 year for neonatal patient (3 ? 18 year).
 3. For children 18 year of age ? 3 year.
 4. For mentally retarded patient forever till hospital/ institution is working.
 5. From income tax point of view for 7 years.

14. HOW TO DESTROY THE RECORDS
 1. Public notice of destroying the records in English news paper and in one vernacular paper mentioning
the
 specific date up to which destruction will be sought
 2. Give a time limit of 1 month for taking away records for those who want the records with written
consent
 3. After 1 month destroy the records up to date specified except for following
 a. Where litigation is going on.
 b. Where future trouble is expected.
 c. Mentally ill or retarded patient.
 d. Pre-litigation process of notice exchange is going on.

15. HARD COPY ONLY
 Computers are now widely used in institution/hospitals for electronic patient records but still hard copy
is required for following documents
 1. Consent need to be on hard copy.
 2. Referral to doctor need hard copy.
 3. Police case need hard copy.
 4. Certificate of fitness should be on hard copy.

16. Regulatory Standards for Medical Records

17. 1. REGULATIONS ON PREPARATION AND PRESERVATION OF
MEDICAL RECORDS
 The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations in 2002 for the first
time mandated the medical practitioners to maintain medical records of patients in the standard format
and to computerize the records for quick retrieval.

18. THE OFFICE MEMORANDUM ISSUED BY THE MINISTRY OF
HEALTH AND FAMILY WELFARE IN 2014 DIRECTS THAT:
 Medical record of In-patients of the last ten years shall be kept in digital format and for future and
medical records of all In-Patients shall be maintained on a regular and continuous basis for future
reference indefinitely,
 A hard copy of medical records of both In-Patient and Out-Patient shall be kept for three years,
 Medical Register and case sheets of medico-legal cases shall be kept for ten years or till the final
disposal of the ongoing cases.

19. EXCEPTIONAL CASES
 The limitation period for filing a complaint under the Consumer Protection Act, 2019 is two years and
the period may be extended if there is sufficient reason to show.51 In such circumstances, the hospitals
will be liable to keep medical records even after three years
 As per the Limitation Act, 1963 in the case of minors, their medical records shall be maintained until they
attain majority.
 Section 29 of the Pre-conception and Prenatal Diagnostic Techniques (Prohibition of Sex Selection) Act,
1994 also prescribes a period of two years for keeping records, charts, consent letters, forms and reports.
If there are any civil or criminal proceedings initiated against any clinics, they are responsible to keep
records till the end of the proceedings.
 Medical Termination of Pregnancy Regulation, 2003 directs clinics to keep admission registers for a
period of five years.

20. 2. TELECONSULTATIONS AND ELECTRONIC MEDICAL RECORDS
Telemedicine Practice Guidelines, 2020 the Registered Medical Practitioners offering online
teleconsultations shall maintain records of the following;
1. Record of Teleconsultation including Phone logs, email records, chat/ text record, video interaction logs
etc.,
2. Patient records, reports, documents, images, diagnostics, data etc. (Digital or non-Digital) utilised in the
telemedicine consultation,
3. Prescription records in the same format as in-person consultations.

21.  The Electronic Health Record Standards, 2016 provides a permanent system of lifelong medical record-
keeping and on the demise of the patient and if there are no cases pending before any court of law such
medical records may be moved from active status to inactive status.

22. III. MEDICAL RECORDS AND PATIENTS’ RIGHTS

23. A. MEDICAL CONFIDENTIALITY
 Generally considered that health information is the patient’s property under the custody of hospitals or
clinics on mutual trust and confidentiality.
 In India, Hospital Manual, 2002 strictly prohibits sharing of health information of patients.
 On the contrary, the Indian Medical Council Regulations, 2002 in the following circumstances a physician
may disclose the secrets of his patients;
 i. in a court of law under orders of the Presiding Judge;
 ii. in circumstances where there is a serious and identified risk to a specific person and/or community;
and
 iii. notifiable diseases.

24. B. MEDICAL PRIVACY
 In India at present, the issues of data protection and privacy rights on information are governed by the
Information Technology Act, 2000.
 As per the Information Technology (Reasonable Security Practices and Procedures and Sensitive Personal
Data or Information) Rules, 2011, medical records are categorized as sensitive personal data or
information of a person.
 And any body-corporate who is possessing, dealing or handling any sensitive personal data or
information must follow the reasonable security practices to avoid the wrongful loss or gain may be held
liable under section 43A of the Act if there is any negligence in following the reasonable security
practices.
 Apart from these statutory provisions, the Mental Healthcare Act, 2017 and the Medical Termination of
Pregnancy (Amendment) Act, 2020 are also providing provisions to protect the general right to privacy
of patients.

25. C. ACCESS TO MEDICAL RECORDS
 right to get information or access to health information is a fundamental right under article 19(1)(a) and
21 of the Constitution.
 Since the medical records are under the possession of the health care providers, the obligation to
provide access to health information is an essential aspect of the medical record-keeping practice.

26.  The Electronic Health Record Standards, 2016 have more detailed provisions for data access with some
limitations imposed on accessing health information. As per the Electronic Health Record Standards, 2016
patients may;
 view and inspect their health data without any time limit and they may restrict access to individually
identifiable health information.
 get a copy of medical records from the healthcare providers within 30 days after submitting a request for that.
 restrict the health care providers from disclosing any specific information temporarily or permanently that
he/she does not want to disclose.
 demand details of the disclosures made including the following;
 a. Date and purpose of disclosure
 b. Name of the person/entity received the information
 c. Brief description of the information disclosed.
 Amend the record to correct errors recorded.

27.  As per Electronic Health Record Standards the healthcare providers may deny information to a patient,
representative or third party in certain circumstances like
 a. Information received under the promise of confidentiality,
 b. Psychotherapy notes,
 c. Information compiled for civil, criminal administration.

28.  The Patients’ Charter also states that patients will have the right to access the original or copies of their
case papers. As per the Charter, investigation reports shall be made available within 24 hours of
admission or 72 hours of discharge. Under the Consumer Protection Act,
 the denial of access to a medical record is considered as a deficiency in service

29. D. RIGHT TO INFORMATION UNDER RTI
 As per the provisions of the Act, public authorities are responsible to give information within thirty days
from the date of receipt of the request. However, if it is information concerning the life or liberty of the
applicant, then the information shall be provided within forty-eight hours of the receipt of the request

30. E. RIGHTS OF DATA PRINCIPAL UNDER THE DISHA, 2018
 Apart from the right to confidentiality/Privacy and access to digital data the Digital Information Security
in Healthcare Act (DISHA) proposes to guarantee the following rights to the owner of digital health data;
 Right to ensure that the data collected is specific, relevant and not excessive in relation to the purpose
for which it is sought,
 Right to know the entity who have accessed the digital health data and to whom it is transmitted.
 Right to rectify any inaccurate and incomplete digital health data,
 Right to require explicit prior permission before each instance of transmission or use of digital health
data.
 Right not to be refused health service in case of refusal to give consent for generation, storage,
transmission or disclosure of digital health data,

31. CARE WHILE ISSUING CERTAIN MEDICAL RECORDS
Prescription
 The prescription should be preferably on the OPD slip of the institution or on the letter pad of the
doctor. Drug company or chemist prescription pad should never be used.
 Prescription must contain—patient’s name, age, sex, address and institution/hospital name. Prescribed
drug should be preferably in capital letter or else clearly visible.
 One should mention its strength (especially in paediatric age group), its dose frequency, duration in
days, and total quantity (number of tablets and capsules). Below the main drug, also mention other
instructions of precautions and what to avoid.
 If any investigation is advised, do not forget to mention it on the prescription slip and call the patient
after the investigation. If patient fails to keep follow up date and if then some complication occurs, then
patient is also considered negligent (contributory negligence)

32. Reports
 All reports i.e. lab investigation, X-ray reports, ultrasound reports, computed tomography (CT-
scan)/magnetic imaging resonance (MRI) reports, and histo-pathological reports should be issued by a
qualified person. Biopsy report should preferably be issued in duplicate so that the referring
doctor/hospital can keep the original copy. If the pathologist does not give a duplicate copy the
referring doctor should get it xeroxed and should be handed over to the patient.

33.  Referral Notes
 Always keep the carbon copy of referral note especially in case of critically ill patient. Referral note
should mention the date and time of writing the note. Also write the treatment given.

34.  Discharge Card
 Consultant in-charge should himself fill or supervise the discharge card. Condition of the patient on the
admission, investigation done, the treatment given and detail advice on discharge should be written on
discharge card.
 Operation notes if mentioned have to be correct otherwise just mention the name of the operation and
give separate note in detail if asked for. If any complication is expected after discharge ask the patient to
report immediately. Instructions while discharge must be very clear and elaborative.
 Keep in mind that abbreviations may not be understood by others. Also do not use code messages,
sarcasm or poor opinion to the patient.

35.  Certificates
 A medical certificate is defined as a document of written evidence vouching for the truth of a fact as
determined by the doctor issuing such a document.
 If medical certificate is admitted in a court of law as evidence and is proved to be false, the issuing
doctor is liable for punishment.

36. PROPER PRESERVATION OF THE MEDICAL RECORDS
 Collect all the records and classify them according to the different section. Protect the records from insect
attack.
 Spray insecticide or place naphthalene balls over shelves to preserve the records.
 Plan a periodical checking for the records.
 Proper care should be observed while handling the records.
 Fire extinguisher should be available in record room.
 Protect all records from dampness, water, and from hot and dry climate.
 Records should be kept in dust free area.
 Windows and ventilators should be properly covered with
 frames as safeguard against sabotage.
 Destroy the records as per the regulation established for retention of records.