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Is it necessary for the doctor to maintain medical records of his patients? |
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Is it necessary for the doctor to maintain medical records of his patients?
Dr KK Aggarwal & Advocate Ira Gupta,  11 July 2019
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It is the duty of doctor or hospital to preserve, maintain the medical record for certain specified period under different laws like Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002, Limitation Act, Consumer Protection Act, 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.

The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002(hereinafter MCI Code of Ethics) provides that

“Duties and responsibilities of the Physician in General:

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 Appendix3.

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.”

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