As a medical practitioner, it is very important that the doctors maintain legal documentation and manage the medical records of the patient properly.

What are medical records?

The medical records include mainly the medical history, the clinical findings, the results of the test carried out, the care administered before operation, the notes which are taken down during the operation of the patient, the care taken after the patients operation is complete and the daily progress of the patient, and also the medications which are prescribed to the patient.

Consent

The consent which is acquired through legal means shall be very helpful to the doctor in the long run. For example consent for major or minor operations or for starting a new course of treatment for the patient’s betterment. And it is the duty of the doctor to acquire consent as per the principles of valid consent which are laid down for reference under the Indian law. Therefore, it is important that the medical staff and other officials at the hospital must be trained in maintaining the medical records of the patient in a systematic manner.

All details regarding maintenance of medical records have been given under the Medical Council of India regulations 2002, and the regulations have laid down certain guidelines with respect to the number of years the medical records of the patient has to be maintained. They are as follows:

1. Every doctor must maintain the medical records of the patient for a minimum period of three years from the date of the treatment of the patient.
2. If a request would be made by the patient or the legal authorities of the court to produce the documents, the medical practitioner shall submit the same within 72 hours, and if the medical practitioner refuses to submit the documents, it might lead to serious consequences.

There are two important reasons why there is a need to maintain the medical records of the patient. They are:

Seamless evaluation of the patient: Maintaining medical records of the patient will be helpful for analyzing and evaluating the patient’s profile and it will also help in analyzing the course of the treatment and the results. It will determine whether the health of the patient is improving or deteriorating and to what extent. It will also assist in planning out future procedures.

Legal documentation: It is always useful in cases where the medical practitioner has been alleged of medical negligence in the court of law. However, it can only be used in the form of documentary evidence when called upon to produce the same. The medical documentation becomes very important while pronouncing a judgment in favour of the medical practitioner. And it shall be helpful in cases with regards to a medical insurance claim with respect to medical negligence from the doctor’s end.

1. Comprehensive: Simple language should be used while recording the data and it should be easily understood by an individual. This step is important for planning, policy-making and making decisions for the patient or for the betterment of the hospital.
2. Proper planning: The medical records must be looked at regular intervals during the working hours of the hospital or the clinic. One must rule out the information from the database of the medical records, which is not required for future reference.
3. Cost-effective way: It is always important that one must maintain the medical records of the patient in a cost-efficient way (electronic records) where no loss is incurred to maintain the medical records of the patients for future reference.
4. Fully accurate: The information which is going to be recorded should be confidential and true in all aspects.

It is the duty of the doctors to maintain the confidentiality of the medical records of the patient. However, in cases of medical negligence; it becomes important to produce the documents in the court of law. If the medical reports, at the time of submission in the court, are well maintained by the doctor, it may be an added advantage to the doctor or any other medical practitioner during the legal proceedings. These legal documents maintained by the medical practitioner hold an evidentiary value.