Medical records- How long one should keep in safe?

 

IMA AP STATE Retention Period of Medical Records- as per various Acts & Organization. (Before destroying the record the hospital has to give Advt. in two news papers,one vernacular paper.
Out patient records	03yrs
Inpatient records	10yrs
Medicolegal case	30yrs or till the final decision of court
Paediatric patients	Till the patient becomes 21yrs old.
Birth &death register	Life time
Casuality register & OT register	30yrs.
MTP register	5yrs
PNDT ACT	2YRS
BMW ACT	5YRS
INCOME TAX ACT	8YRS
ICMR GUIDELINES-ART	10YRS-National registry
Surrogacy bill	25yrs
Consumer protection act	2yrs
Civil litigations	3yrs
Criminal laws	2yrs
NMC ACT

  

QUERY:

Is it obligatory for hospitals to provide copy of the case record to patient or his legal representative?

OPINION:

Yes, it is obligatory for doctors, hospitals to provide the copy of the case record or medical record to the patient or his legal representative.

The preamble to the Constitution of India coupled with the Directive Principles of State Policy strives to provide a welfare State with socialist patterns of society. It enjoins the State to make the “improvement of public health” a primary responsibility.

Furthermore, Articles 38, 42, 43 and 47 of the Constitution provide for promotion of health of individuals as well as health care.

The Constitution of India also enumerates the separate and shared legislative powers of Parliament and State Legislatures in three separate lists: the Union List, the State List and the Concurrent List.

The Parliament and State legislatures share authority over matters on the Concurrent List, which include criminal law and procedure.

Health service includes securing citizen from medical negligence by punishing concerned for crime of medical negligence and compensating the damage caused by doctor or hospital through negligence under tort action or securing the enforcement of contractual obligation under law of contract.

A patient should be given medical records in Appendix 3 with supporting documents. “The Patient has a right to his/her medical record and Respondent Hospital Authorities have a duty to provide the same under Right to Information Act, 2005, Consumer Protection Act, 1986, The Medical Council Act as per world medical ethics.

 

Consumer Protection Act is another legislation which is aimed at preventing negligence and deficient services besides assuring right to information about medical treatment given to the patient at the threat of imposing compensation.

The Medical Council of India has imposed an obligation on Hospitals as per the regulations notified on 11th March 2002, amended up to December 2010 to maintain the medical record and provide patient access to it. These regulations were made in exercise of the powers conferred under section 20A read with section 33(m) of the Indian Medical Council Act, 1956 (102 of 1956), by the Medical Council of India, with the previous approval of the Central Government, relating to the Professional Conduct, Etiquette and Ethics for registered medical practitioners, namely:

Maintenance of Medical Records:

1.3.1. 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 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.

MCI ethics regulations 7.2 further clarifies that not giving records can amount to professional misconduct.

Misconduct: “7.2 If he/she does not maintain the medical records of his/her indoor patients for a period of three years as per regulation 1.3 and refuses to provide the same within 72 hours when the patient or his/her authorised representative makes a request for it as per the regulation 1.3.2.”

With the enforcement of the MCI Regulations, 2002 it is made clear that the patient has a right to claim medical records pertaining to his treatment and the hospitals are under obligation to maintain them and provide them to the patient on request

 

Few judgments :

In Kanaiyalal Ramanlal Trivedi v Dr. Satyanarayan Vishwakarma 1996; 3 CPR 24 (Guj); I (1997) CPJ 332 (Guj); 1998 CCJ 690 (Guj), The Hon’ble High Court of Gujrat.

In Raghunath Raheja v Maharashtra Medical Council, AIR 1996 Bom 198, Bombay High Court upheld the right of patient to medical record very emphatically. Judges

In the matter titled as P.P. Ismail v K.K. Radha 1997 (2) CPR 171 (NC); I(1998) CPJ 16 (NC); (1997) 5 CTJ 685 (CP) (NCRDC); 1999 CPJ 99 (NC), the Hon’ble National Commission for Consumer Dispute Redressal Forum.

In S. A. Quereshi v Padode memorial Hospital and Research Centre II 2000. CPJ 463

In case of Dr. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya 2002;1 CPR 320, I (2006) CPJ 16 (NC), the Hon’ble National Commission of Consumer Dispute Redressal Forum.

The Hon’ble Kerala High Court in the matter titled as “Rajappan Vs. Sree Chitra Tirunal Institute for Medical Science and Technology [ILR 2004 (2) Kerala 150]” .

 

The Hon’ble Central Information Commission has examined the issue of right of patient to have the medical records in the matter titled as Nisha Priya Bhatia v Institute of Human Behaviour and Allied Sciences GNCTD, bearing File No.CIC/AD/A/2013/001681SA vide order dated 23.07.2014 .

In the matter titled as Shri Prabhat Kumar versus Directorate of Health Services, GNCTD, Delhi, the Hon’ble Central Information Commission vide order dated 07.04.2015.

 

A Bombay High Court ruled against Ruby hall clinic and said that patient has a right over his record with the hospital and hospital should provide copy of it within a reasonable time ( MMC says 3days ) and hospital is entitled to charge a reasonable amount for the same.

A hospital should provide a copy of the patient's medical record when requested by the patient. But the above right cannot be enforced under the MCI, 2002, Regulations.

The patient's indoor medical case sheet is a property of the hospital and the patient has only a right to get a copy, not the original record.

How long records of patients should be maintained?   • As per the proposed / draft “Clinical Establishments (Registration and Regulation) Rules, 2010,  “Copies of all records and statistics shall be kept with the clinical establishment concerned for at least 3 or 5 years or in accordance with any other relevant Act in force at the time”.   • As per Regulation 1.3.1 of the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, “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”.   • As per Rule 6F (3) of the Income Tax Rules, 1962, doctors in private practice are required to preserve the daily case register as per Form 3C for a period of six years from the end of the relevant assessment year. That would ordinarily mean for seven years from the close of the accounting year.   • As per Punjab Medical Manual (1934), the medicolegal record is to be preserved for 12 years.   • As per the DGHS vide letter No. 10-3/68-MH dated 31-8-68, records should be maintained as follows: For inpatient medical records (case sheets)……………….10 years For medico-legal registers…………………………………….10 years For outpatient records………………………………………….5 years The above requirement can be found in the “Hospital Manual” published in 2002 by the Directorate General of Health Services, MOHFW, GOI, in chapter 12 titled “Medical Record Services”.

In summary medical records belong to the medical professionals / entities but patients generally have a right to review them, demand copies of them, and to demand their confidentiality as per the MCI/ NMC ethics regulations.