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Can a patient obtain medical records?

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Dr KK Aggarwal & Advocate Ira Gupta    21 June 2019

Yes, patient can obtain medical records from the doctor and hospital. It is the legal right of the patient to obtain medical record.

The Hon’ble National Consumer Disputes Redressal Commission in the matter titled as Dr. Paramjit Singh Grewal vs Charanjit Singh Chawla vide judgment dated 19 October, 2006 held that

“It is high time that Doctors write correct notes in the operation record and discharge summary. These documents should be made available to the patient at any time without any hue and cry. When information is given orally, it becomes a matter of debate as to who is telling the truth. It is patients right to know how his case has been dealt with by the treating Doctor. It will also enable him to follow the treatment prescribed for future and, if required, sometimes, even to take a second opinion of an expert. It is the duty of the Doctor to state in the record all the details of the treatment given, medicines which are prescribed and the follow up advice, if any, and give it to the patient for his reference. Patient has a right to get the medical record pertaining to him and he cannot be denied the same when he paid the Doctor/Hospital for his treatment and hired the services.”

Even as per Clause 1.3.2 of the MCI Code of Ethics, it is the duty of the doctor to provide the medical record to the patient or his/her authorised representative. The provision is reproduced hereunder:

“Duties and responsibilities of the Physician in General:

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.

If the patient or any of his/her authorised representatives makes a request for the medical record and the doctor refuses to provide the medical record to the patient within a period of 72 hours (i.e. 3 days) then the doctor is liable for professional misconduct. The provisions of MCI Code of Ethics are as follows:

“7. Misconduct: The following acts of commission or omission on the part of the physician shall constitute professional misconduct rendering him/her liable for disciplinary action:

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.“

In the case of Dr. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya I (2006) CPJ 16 (NC), the Hon’ble National Commission of Consumer Disputes Redressal said that not producing medical records to the patient prevents the complainant from seeking an expertopinion and it is the duty of the person in possession of the medical records to produce it in the court and adverse inference could be drawn for not producing the records.

The Hon’ble Central Information Commission in the matter titled as “Mrs Anita Singh vs Gnctd, CIC/SA/A/2015/001894 order dated 16 March, 2016 observed that three enactments RTI Act, Consumer Protection Act and Medical Council Act, provided the appellant a strong and undeniable right to information to the patient of his/her own medical record. The Right of patient to Information to his/her own medical record is not only guaranteed under above three legislations but also rooted in Article 19 and 21 of the Constitution of India, 1950. This right is not limited to records held by public authorities alone but extends to all hospitals including private or corporate hospitals also to individual doctors, who treat patients.

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