MEDICAL RECORD AND ITS IMPORTANCE
DR. ROSHAN GARG, SENIOR CONSULTANT ANAESTHESIOLOGIST
The first person who maintained a ‘Medical Record’ was ‘HIPPOCRATES’. Medical Record keeping is not a legal requisite but is mandatory. Medical Record is defined as a ‘CLINICAL, SCIENTIFIC, ADMINISTRATIVE AND LEGAL’ written document of information pertaining to a patient’s health care, in which the recorded data is in sufficient sequence of events, to justify the diagnosis, treatment and outcome.
Therefore, a medical record contains information on diseases, health risks, diagnosis, investigations, examination, therapies, follow up, prognosis and discharge status.
A medical record must fulfil the following criteria:
1. Complete: The record should be complete and must contain sufficient data to identify the patient and justify diagnosis, treatment given and outcome. It must contain the basic records, nurse’s bed side record and special record, if any.
2. Adequate: Record should not be sketchy and must contain all necessary forms and relevant clinical information.
3. Accurate: Should be easy to subject to quantitative analysis.
4. Legible: The record should be legible. Names of all the signatories should be written in capital letters and followed with a stamp.
The medical records must be considered from two angles.
1. Personal Document: The information contained in the medical record is confidential, privileged and cannot be made public without the consent of the patient, except under due process of law. Information regarding patient’s admission, discharge or condition and birth or death of a child can only be given to the relatives or friends.
2. Impersonal Document: The content of the records can be used for education, research and for public health without revealing the patient’s identification.
Ownership of Medical Records
Medical record is the property of the hospital. The hospital is the owner and custodian of the document. The patient, the attending doctor or clinical department has no right over the medical record. If the attending doctor wants to go through the record of a patient, it is a courtesy extended by the hospital and not a matter of right for the doctor.
How long Medical Records should be retained
General guide to retain the record is-
1. OPD Records – 5 years.
2. Indoor Records – 10 years. Active Record {first three years}
Passive Record {Remaining seven years}
3. Medico legal Records – Permanent or till the case is vacated from the court.
Responsibility of safe keeping of Records
The administration is responsible for the safe keeping of medical records.
A proper record of movement of medical record from indoor to Medical Record Department (MRD) or wherever the documents are taken out for education and research purpose should be maintained at the MRD.
All medico legal records should always be kept in safe custody, that is under lock a key. A single person, preferably a medical record officer or person designated by the hospital authority should control the medico legal records.
Importance of Medical records
The Medical record helps the patient, protects the doctor and acts as a shield for the hospital. The medical records are important for
1. Patients:
a) The primary reason for record keeping is to improve patient care.
b) To maintain continuity of medical care.
c) Save patients from repeated irksome tests, therapies and procedures.
c) Provide legal protection to the patient.
2. Doctors:
a) An assurance of orderly continuity of medical care.
b) Assurance of quantity, quality and adequacy of diagnosis and therapeutic
procedures undertaken.
c) An evaluation of medical care rendered.
d) Provides legal protection by justifying the doctor’s stand.
d) Teaching and Publication purposes.
3. Hospital:
a) To evaluate the type, quality and quantity of services rendered by the hospital
to its clients.
b) To exercise administrative control.
c) To protect the hospital in case of legal litigations for negligence /
malpractices / injuries / deaths.
d) To assist in future programming and planning.
e) To serve as a tool for growth of the hospital with regard to physical facilities,
staff, equipments and finances. Medical Record acts as a Hospital
Management Information System.
4. Medical Education and Research:
a) Medical records are useful documents to educate doctors and other health
personnel.
b) Recorded observations are the basis for all clinical, administrative and preventive research.
c) It forms an important and integral part of health information system at the national and international level to supply data for control of diseases and prevention of epidemics.
Who can ask for Medical Records
The medical records are documentary evidence under the Indian Evidence act of 1872. In the following situations, the Hospital representative or treating medical officer may be required to produce the records.
1. In the court of law:-
The court may ask for medical documents in the following conditions-
(i) Malpractice suits against the hospital employee or hospital itself in view of – Injury due to negligence or Medical examination or surgical intervention carried out without consent, which usually amounts to assault.
(ii) Cases in consumer courts for claims.
(iii) Medico legal cases in criminal courts – The medical officer is required to inform the police about the injuries. The Hospital cannot be forced to handover the record to the patient or the police. The medical record is produced in court in case of a summons.
2. L.I.C of India-
May ask for hospitalization details or cause of death to dispose of the claim.
3. Income Tax-
This department may ask for the hospitalization record and information has to be
provided without the patient’s permission.
4. Patient Will-
Except mentally ill patients, any other patient who desires to make his will, is
ordinarily allowed to do so.
5. Queries regarding Birth and Death
Medical documents may be required to confirm the authenticity of these
certificates.
Medical audit
The medical audit is a systematic approach to peer review of medical care, in order to identify opportunities for improvement. The medical audit is an internal system of a hospital. It allows for improving functioning of the hospital and for evaluating quality of patient care on the basis of documented evidence and not fault finding.
Medical audit is a retrospective analysis of medical records and is possible, only if medical records are well maintained.
Advantages of Medical Audit:-

1. Based on this analysis, we find out the acts of omissions, commissions and deficiencies etc. as committed by doctor or nurses. These should be avoided in subsequent patient admissions in the same disease category.
2. A good medical record speaks about the physician in-charge in his absence. It also reveals or reflects the quality of patient care.

DR. ROSHAN GARG
SENIOR CONSULTANT ANAESTHESIOLOGIST
ISA Membership G 0345
Mobile: 9810162887