NO RECORD IS NO PROOF, POOR RECORD IS POOR PROOF -Importance of keeping the Medical Record - Adv. ROHiT ERNADE. ©

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

Adv. ROHiT ERANDE. ©

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 RECORD  IS NO PROOF, POOR RECORD IS POOR PROOF "

In one of the case before the NCDRC, the moot question was whether a Patient who was admitted in an emergency ward and later on discharged after initial treatment can be regarded as the OPD patient or IPD Patient ? As the deceased patient after meeting with an accident came to the Hospital and after CT Scan, X-ray etc. were done and his left hand was plastered,  he was discharged from the Hospital. But when he reached 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. On the way to the Higher Center only the patient died. The legal heirs filed a case of medical negligence and the Hospital denied the same. 

The records of the first Hospital were called, the hospital took the defense that since the deceased was an OPD patient, records have not been maintained. 

It was held by NCDRC that no negligence can be attributed to the hospital as the deceased was never admitted as in IPD patient, thus records are not required to be kept for 3 years 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. 

(Ref : Mahaesh Prasad Agarwal & ors.  V/s.  M/s. Kamayani Patients Care India Ltd, Agra, U.P. Ori. pet. No.39/2003. Decided on : 03/01/2013,  (by Hon. Justice K.S. Chaudhari, Presiding Member and Suresh Chandra , Member)


Now let's see the code of ethics which 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 (very important - so the liability is of the Doctor and not the hospital) 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.

Failure to maintain Medical Record amount to Professional Misconduct - 

If the Doctor fails to maintain the record as per regulation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorized representative makes a request for it, it amounts to professional misconduct and the Doctor will be liable for the disciplinary action.  

In the Court of law, only Record speaks and therefore there is no alternative in maintaining the record. 

Read the following blog to know why an Orthopedic Surgeon was ordered to  Rs. 4 lakhs for not keeping proper medical record.

https://advrohiterande.blogspot.com/2019/02/rs-4-lakhs-doctors-paid-for-not-keeping.html

If we see other enactments like Sec.29 r/w rule 9(6) of PCPNDT ACT,  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. This would be applicable for any other medico-legal cases

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.

Conclusion : 

1. In the Court of law, only Record speaks as it becomes the Evidence and therefore there is no alternative in maintaining the record and that too in time. 

2. Never try to alter or modify the records.  don not delegate your work of writing OT notes etc and if you do, then please read it carefully before signing it. Few minutes spent in reading would act as a stitch in time ! 

3. If you are issuing Certificates /Prescriptions in writing /physically, keep a carbon copy with you. 


Thanks and Regards,


Adv. Rohit Erande

Pune. ©


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