THE SIGNIFICANCE OF MAINTAINING PROPER HOSPITAL RECORDS
Dear Readers,
It is always a pleasure to me to interact with the medical fraternity. In the past I have shared my views on various topics but the present topic of maintenance of accurate records by the hospital is of most concern to me as a doctors- lawyer.
The position which actually emerges is that when a case is filed by a patient against a doctor or a hospital in a consumer court and when the stage of filing of defence on part of the doctor comes, as I can say so on the basis of vast experience of having appeared in several hundred medical negligence cases by now ; properly maintained hospital records is the only tool by which I can strongly make out a case in favour of the doctor/hospital. My view is fortified by a very recent decision of the Hon'ble National Consumer Commission in the case of N.J. Karnavat (Dr.) Vs. Patel Ishwarlal Mangallal and others decided on 07th October 2014 wherein it has been clearly held by Hon'ble National Commission that -
Qoute:-
"For importance of medical records, we have perused an article titled "Medical records and issues in negligence" by Joseph Thomas, Indian J Urol. 2009 Jul - Sep; 25 (3): 384 - 388; the author mentioned that,
it is frustrating to note that in spite of knowing the significance of proper record keeping it is still in a nascent stage in India. It is wise to keep in mind that "poor records mean poor defence, no records means no defence". Medical records consist of a variety of certification of patient's history, medical findings, diagnostic test results, preoperative proper care, function notes, post surgical care, and daily notes of a patient's progress and medications. An effectively acquired consent will go a long way in showing that the procedures were conducted with the concurrence of the sufferer. An effectively written operative note can secure a surgeon in case of alleged carelessness due to operative problems. It is essential that the prescribed for drugs should be readable with the name of the patient, date, and the signature of the doctor. An undated prescribed can land a doctor in trouble if the patient misuses it.
The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, states that every physician shall maintain the medical records pertaining to his / her indoor patients for a period of three years from the date of commencement of the treatment. If any request is made for medical records either by the patients/ authorised attendant or legal authorities involved, the documents shall be issued within a period of 72 hours and refusal to do so would be misconduct."
Thus it can be seen that a very important point of law in so far as the question of maintaining of hospital records is concerned has been decided by the court and which should now be followed as a rigorous guidelines by the entire medical fraternity.
Lucknow
April 15, 2015 |
