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HEALTH AND LAW

Medical records

K Mathiharan

DOI: https://doi.org/10.20529/IJME.2004.029


Well-maintained medical records will unquestionably help doctors and hospitals in their defence in cases of medical negligence.

In Md. Aslam v. Ideal Nursing Home (1), the State Commission made a strong note of the lack of regulations governing nursing homes and made suggestions regarding medical record-keeping. In Poona Medical Foundation Ruby Hall Clinic v. Marutirao L. Titkare (2), the National Commission held that not providing medical records did not constitute negligence or deficiency in service, as there was no legal duty cast to furnish such documents to a patient. It further held that no material was placed before the Commission to show that either by law, or by convention or by practice, was there any obligation on the part of the hospital to furnish to the patient full particulars of the surgical operation performed on him.

In January 1996, the Bombay High Court (3) held that doctors and hospitals should make medical records available to patients or their near relatives on demand, after levying an appropriate fee. It further held that doctors and hospitals could not claim any secrecy or confidentiality in the matter of copies of the case papers relating to the patient.

The Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002 (4) 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.

In many countries, the doctors or hospitals that ask for the tests are the owners of the X-ray films and other investigational and case records. A patient can get a copy of it only when he/she is referred to another doctor or decides to file a suit against the doctor/hospital. In the UK to overcome the doctors’ concern and to maintain patients’ confidentiality the following Acts are in force.

According to the Data Protection Act, 1984, an individual should be informed by anyone holding computerised information whether that information includes his/her personal data and should be supplied with copies of it. The Access to Medical Reports Act, 1988 states that insurers and employers may not be shown a report until the patient has seen and commented on it and has consented to its disclosure. According to the Access to Health Records Act, 1990 patients have access to their health records.

Manipulated medical records, failure to deliver X-ray films and statement of accounts of a hospital, and improperly maintained medical records were considered deficient services by the Consumer Disputes Redressal Agencies.

  • In Nihal Kaur v. Director, PGI, Chandigarh (5), the State Commission held negligence on the basis of the records, which seemed to be manipulated.
  • In V P Shanta v. Cosmopolitan Hospitals (P) Ltd (6), the State Commission held that failure to deliver X-ray films is deficient service. The patient and his attendants were deprived of their right to be informed of the nature of injury sustained.
  • In Force v. M Ganeswara Rao (7), the State Commission held that there was negligence as the case sheet did not contain a proper history, history of prior treatment and investigations, and even the consent papers were missing.
  • In Dr C Venkatasamy, Director, Aravind Eye Hospital v. N Mariappan, (8) the hospital rendered free treatment to a patient in an eye camp and claimed that he did not come under the Consumer Protection Act. When the complainant petitioned for summoning the statement of accounts, the hospital refused to part with it and filed a Revision Petition.

References

  1. Orissa SCDRC 1994 (1) CPR 619.
  2. NCDRC 1995 (1) CPJ 232: 1995 (1) CPR 661 (NCDRC) 1996 CCJ 70.
  3. Raghunath G. Raheja v. Maharastra Medical Council (198 Bom AIR 1996).
  4. In Section 1.3 Subsections 1.3.1 and 1.3.2.
  5. 1996 (3) CPJ 112 (Chandigarh (U.T.) CDRC).
  6. 1997 (1) CPR 377 (Kerala SCDRC).
  7. 1998 (3) CPR 251; 1998 (1) CPJ 413 (AP SCDRC).
  8. Tamil Nadu State Consumer Disputes Redressal Commission in order R.P.No.15/1998 dated 18/10/2002.
About the Authors

K Mathiharan ([email protected])

Advisor

Institute of Legal Medicine, New No. 53, Fifth Street, Padmanaba Nagar, Adyar, Chennai 600 020

Keywords

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