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Are doctors supposed to share the pictures or video recording of surgery or any case notes other than the discharge summary?
Yes, it is obligatory for doctors, hospitals to provide the copy of the case record or medical record and also share the pictures or video recording of surgery or any case notes other than the discharge summary to the patient or his legal representative as the patients generally have a right to review them, demand copies of them, and to demand their confidentiality as per the MCI ethics regulations.
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:
1.3 Maintenance of medical records:
1.3.1 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.
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.
1.3.3 A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2.
1.3.4 Efforts shall be made to computerize medical records for quick retrieval.
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
In Medi. Supri. Loaknayak Jaiprakash Narayan Hospital & Ors. V/s. K.M. Santosh. F.A. No. 244/2008, decided on 14/03/2016, the National Consumer Disputes Redressal Commission observed
“5. It is the primary responsibility of the hospital to maintain and produce patient records on demand by the patient or appropriate judicial bodies. However, it is the primary duty of the treating doctor to see that all the documents with regard to management are written properly and signed. An unsigned medical record has no legal validity. The patient or their legal heirs can ask for copies of the treatment records that have to be provided within 72 hours. The hospital can charge a reasonable amount for the administrative purposes including photocopying the documents. Failure to provide medical records to patients on proper demand will amount to deficiency in service and negligence. It is the duty of doctor or hospital to preserve, maintain the medical record for certain specified period under different laws like Limitation Act, Consumer Protection Act and the Directorate General of Health Service (DGHS), Prenatal Diagnostic Test Act, 1994, the Clinical Establishments (Registration and Regulation) Act, 2010 (Central Act No. 23 of 2010). These records are required in medical negligence, accident, insurance claims and in criminal cases also in the Labour Courts. Hon’ble Supreme Court and the National Consumer Commission in various judgments held the hospitals/doctors liable for medical negligence for non-production of medical record.
6. “Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others.” I have explained previously also about umpteen no of judgments which underlines the importance of keeping proper record & documentation and also the ill effects of failure. There is no escape for proper documentation. Always remember POOR RECORD IS POOR DEFENSE AND NO RECORD IS NO DEFENSE.
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 ethics regulations.