Medicolegal questions on documentation & record keeping
M3 India Newsdesk Mar 03, 2020
Medicolegal experts answer common questions pertaining to the importance of documentation and record keeping and time period for which they should be maintained.
What is the meaning of document?
Indian Evidence Act – 1872 and Indian Penal Code Section – 29 defines document as,
Any matter expressed or described upon any substance by means of letters, figures or marks, or by more than one of those means, intended to be used, or which may be used, for the purpose of recording that matter.
What is the importance of a document?
“Courts are not the courts of justice, they are the courts of evidences.”
Courts are blind. They decide on the case only on the basis of evidences produced in front of them. The only evidences in case of medical professional are their documents. It is said that,
- Good documents = Good defence
- Poor documents = Poor defence
- No documents = No defence
It is the most tedious job but still there is no excuse in the law for documentation and record keeping.
Why should one keep documents?
A doctor is bound to produce records when asked by the court and if he does not produce the same, adverse inference might be drawn. Under some acts, it is punishable too.
Section - 1.3.2 of The Indian Medical Council (Professional conduct, Etiquette & Ethics) Regulations, 2002 – If any request is made for medical records either by the patient or authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within a period of 72 hours. Failure to issue the same will be regarded as misconduct as per Section 7.2.
Certain provisions of Clinical Establishment act and Different Nursing Home Registration Acts mandates to keep certain documents.
How long should documents be preserved?
Under different Acts there are different guidelines for the period of preservation of records.
- Consumer Protection Act - 2 years (from cause of action)
- Civil Litigations - 3 years
- Income Tax Act - 8 years (6 Years from the assessment year)
- Criminal Laws - No limit
- PNDT Act - 2 years
- MTP Act - 5 years
- ICMR Guidelines - 10 years and then to be submitted to registry
- FOGSI Guidelines - At least 5 years
- MCI Guideline - 3 years (Section – 1.3.1 of Code)
Which documents are to be maintained?
Medical records
- OPD case paper
- Indoor case paper
- Consents
- Prescriptions
- Discharge card
- Investigations
- Refer notes
- Requests for investigation
- Reports of Investigations – Pathology testing, ECG, X-rays, CT scans, MRI etc.
- CDs or DVDs
- Medical certificate if given
- Forms
- Registers
Registers
- OPD case register (3-C register)
- Indoor case register
- Nursing order book
- Operation theatre register
- Autoclaving register
- Fumigation register
- Biomedical waste register
- PNDT register – (PC-PNDT rule – Section – 9(1))
- MTP Register – (Admission Register – Form-III)
- Sterilisation and IUCD register
- Birth and death register
- Medical certificate book – as per MCI guidelines
- Drug register
- Vaccination register
- MLC register
- Indoor case as per MCI guidelines
- Discharge card as per MCI guidelines
- DAMA certificate
- Files- Gynaecology and obstetrics
- Death certificate
- Registers under different acts – Labour laws, NH Registration Acts etc.
Indoor case papers- Fully written-up contemporaneous records with all details
- Registration form
- Admission consent
- Chief complaint, histories and examinations reaching provisional diagnosis
- Investigations (all reports of investigation) and confirmation of diagnosis
- Counselling (medical, financial, psychological) and plan of treatment
- Consents, pre-op orders and check-ups (physician, anaesthetic)
- Pre and per-op anaestheic note and operative note (detailed steps with reasoning of decisions if changed)
- Post-operative examination and order
- Nursing chart
- Discharge card
- Check list if any
- Paginate the indoor case and send it to MRD department
How to maintain records?
Record keeping is an art. There are more than 150 Acts which are applicable to one clinical establishment. Some of them known and some are not known to a common practitioner. It is advisable to keep one BOX file for each Act. All relevant papers of that particular Act are to be kept in one BOX File so that, whenever asked for can be easily retrieved. Day to day update of the files is necessary.
Few extra tips on record keeping
- Keep the records of visiting doctors in their own handwriting or signed by them.
- Keep originals in your custody and give photocopy if demanded.
- Avoid overwriting. Alteration should never be done. Altered notes can lead to loss of credibility.
- Additions with fresh date and time are allowed.
- Every page should contain the name and registration number of the patient.
- Date and time should be mentioned at each entry.
- Every doctor writing notes has to sign at the end with name.
Where should documents be kept?
Every hospital should have a separate MRD room. Efforts should be made to digitalise the records for quick retrieval. (Sec. 1.3.4 of IMC Code). Agencies are there which keep records digitally by scanning.
How should documents be destroyed?
After passage of the requisite time under different laws, one can destroy the documents after giving public notice of reasonable time in two local daily newspapers, one in English and one in the regional language.
Good documentation is a reflection of good patient care. It improves the quality of medical establishments. Good documentation saves the medical practitioner in the court of law most of the time. So documents should be accurate, complete, legible and free of extraneous information.
Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.
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