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Is it necessary for the doctor to maintain medical records of his patients?

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Dr KK Aggarwal & Advocate Ira Gupta    23 September 2020

It is the duty of the doctor or hospital to preserve and maintain the medical record for certainspecified period under different laws like Indian Medical Council (ProfessionalConduct, Etiquette and Ethics) Regulations, 2002, Limitation Act, ConsumerProtection Act, the Directorate General of Health Service (DGHS), PrenatalDiagnostic Test Act, 1994, the Clinical Establishments (Registration and Regulation)

Act, 2010 (Central Act No.23 of 2010).These records are required in medicalnegligence, accident, insurance claims and in criminal cases and also in the LabourCourts.

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 indoorpatients for a period of 3 years from the date of commencement of the treatment in astandard 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/authorized attendant or legal authorities involved, the same may be duly acknowledged anddocuments shall be issued within the period of 72 hours.

1.3.3 A Registered medical practitioner shall maintain a Register of MedicalCertificates giving full details of certificates issued. When issuing a medicalcertificate, he/she shall always enter the identification marks of the patient and keepa copy of the certificate. He/She shall not omit to record the signature and/or thumbmark, address and at least one identification mark of the patient on the medicalcertificates 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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