Medical Records of "INDOOR PATIENTS" are to be maintained for 3 years. No direct obligation incase of OPD Patients. -Adv. ROHiT ERANDE

 Medical Records of "INDOOR PATIENTS" is to be maintained for 3 years. No obligation incase of  OPD Patients record.

Every Doctor / hospital will agree that maintaining of record of patients is a herculean task. The number of patients examined in OPD (Outdoor Patient Department) are much more than the IPD (Indoor Patient Department) One may like it or not, but there is no excuse. Most of the cases of Medical Negligence are either won or lost by doctors on the basis of documentation. 

Always remember " NO DOCUMENTATION IS NO PROOF, POOR DOCUMENTATION IS POOR PROOF"

Law study is a continuous process and sometimes you come across with important judgment to be shared with everyone. Many a times a question is asked was to whats the period of maintaining/ keeping the record ? The answer to this  has been given by Hon. NCDRC  in the year 2013. 

Lets see the case details in short :

Case Details :

Ori. pet. No.39/2003.

Mahaesh Prsad Agarwal & ors. 

V/s. 

M/s. Kamayani Patients Care India Ltd, Agra, U.P.

Decided on : 03/01/2013,  (by Hon. Justice K.S. Chaudhari, Presiding Member and Suresh Chandra , Member)

The judgment Link :

https://indiankanoon.org/doc/188669828/

Facts of the case in short :

1. The complaint was filed by the Widow and minor children on account of death of deceased Mr. Rajeev Agarwal for getting compensation of Rs.30 lakhs against the Hospital.

2. The matter goes back to somewhere October- 2001. Late Mr. Rajeev Agarwal while returning to Agra met with an accident as his vehicle overturned. He was immediately taken to the opposite party - Hospital at Secundara. In the Hospital CT Scan, X-ray etc. were done and his left hand was plastered and then he was discharged from the Hospital.

3. It's the case of the Complainants that he was told by the Hospital that the deceased was alright, however no discharge documents were given to him. In the said Hospital, late Mr. Agarwal was complaining of severe back and head pain, but it was ignored and no treatment was given.

3. When he returned home, he could not move his hands and legs beside severe pain in head and back and thus it was decided by the family members to shift him to the higher center in Delhi. An ambulance was also hired. Unfortunately  when the proceeded to Delhi, merely after 20 kms Late Mr. Agarwal collapsed. The relatives asked for the entire medical record, but the opposite hospital refused. 

4. It was alleged that the Opposite party - Hospital did not give proper medical treatment, nor did they advise for any operation. From the post mortem report it was revealed that, deceased had fracture of left partial bone, there was evidence of haematoma of left side of Brian and even membranes were found to be congested. Considering the 41 age of the deceased, his annual income of Rs.3 lakhs  and his dependants , total claim of Rs.30 lakhs was made.

5. It was argued that as per the notification dated 11/03/2000, issued by the MCI and the Chapter-I, Para-1.3 of Code of Ethics, the record of Indoor Patient has to be maintained for 3 years.

Defense of the Hospital :

1. The hospital refuted all the charges of negligence. It was contended that the deceased was the Outdoor Patient and was given all the emergency treatment. 

2. The regular fees was charged. On duty doctors vehemently advised the deceased to get admitted in the hospital itself, but the father of the deceased and his brother Dr. Rohit Agarwal were of firm view of not admitting the deceased in the opposite party Hospital and took the deceased against the medical advise. 

3. It was contended that the deceased was not in a position to be taken to Delhi, it would have been better had he been admitted to the said Hospital only. It was also denied that the Hospital was ever asked for the records. 

Held ;

The moot question before the National commission was whether the deceased was Indoor Patient or not ?

1. After perusing the record, hearing of the parties, the National Commission dismissed the Complaint.

2. It was revealed by the affidavit filed by one Dr. Gupta for the Hospital that on the aforesaid day, total 4 patients were admitted as IPD patients and the deceased was not admitted as an IPD patient and therefore as he being an OPD patient, his medical record was not maintained. 

3. The commission also did not believe in the affidavit filed on behalf of the Complainant that fro mythe opposite party hospital, the deceased was taken directly to his home, when admittedly the deceased could not move his hands and legs beside severe pain in head and back. 

4. The Commission further observed that the deceased either would have been brought to said Dr. Rohit Agarwal's hospital, as it was in the same city and was giving 24 hrs facility for accident patients or he would have been admitted to some other Hospital. The Commision further observed that Complainants also could not explain as to after discharging from the Hospital and before taking to Delhi, where the patient was kept for 24 hours  and rather they suppressed the treatment given in said 24 hrs. 

5.  It was held that no negligence can be attributed to the hospital as the deceased was never admitted as in IPD patient and he was taken against the medical advise of the on duty Doctors in the Opposite Hospital and the Complainants also suppressed material fact about the treatment given for 24 hrs after the discharge and before approaching towards Delhi. 

6. this is a very important case. It revolves around the maintenance of Record, something that make Doctors  jittery. The code of ethics are clear about maintenance of record in case of IPD patients, same is reproduced as under. however there is no express provision for Outdoor Patients Record. :

1.3 Maintenance of medical records: 

1.3.1 Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3. 

1.3.2. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. 

1.3.3 A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2. 

1.3.4 Efforts shall be made to computerized medical records for quick retrieval.

In case of PCPNDT Act :

Pls see Sec.29 r/w rule 9(6) of PCPNDT ACT. In short it says all such record is to be maintained for period of 2 years and in case of court case, till the final disposal of such case.
29. Maintenance of records.
(1) All records, charts, forms, reports, consent letters and all other documents required to be maintained under this Act and the rules shall be preserved for a period of two years or for such period as may be prescribed: Provided that, if any criminal or other proceedings are instituted against any Genetic Counselling Centre, Genetic Laboratory or Genetic Clinic, the records and all other documents of such Centre, Laboratory or Clinic shall be preserved till the final disposal of such proceedings.

As per the notification bearing no.  G.S.R. 486 (E) dated 13th June April, 2003  – In exercise of powers conferred by section 7 of the Medical Termination of Pregnancy Act, 1971 (34 of 1971), the Central Government hereby makes the following regulations, namely : 

Maintenance of Admission Register, - 

1. Every head of the hospital or owner of the approved place shall maintain a register in form III for recording there in the details of the  admissions of women for the termination of their pregnancies and keep such register for a period  of five years from the end of the calendar year it relates to.  

2. The entries in the Admission Register shall be made serially and a fresh serial shall be started at the commencement of each calendar year and the serial number of the particular year shall be distinguished from the serial number of other years by mentioning the year against the serial number, for example, serial number 5 of 1972 and serial number 5 of 1973 shall be mentioned as 5/1972 and 5/1973. 

3. Admission Register shall be a secret document and the information contained therein as to the name and other particulars of the pregnant woman shall not be disclosed to any person. 

As stated earlier and it has been held in numerous cases that maintaining the record has no alternative. Now a days almost every where fro OPD patients computer generated record is maintained. For IPD also such digital record is maintained, but case papers etc. are still written on papers. Thus it may be concluded that for IPD patients, 3 years rule of record maintaining is a must, but not for OPD Patients. 

Thanks and Regards,

Adv. Rohit Erande

Pune. ©