Patient Record Presented by:- susmita chakrabarty

A good medical record serves the interest of the medical practitioner as well as his patients. It is very important for the treating doctor to properly document the management of the patient under his care. Medical record keeping has evolved into a science. The key to dispensability of most of the medical negligence claim rest with the quality of the medical records. Record maintenance is the only way for the doctor to prove that the treatment was carried out properly. Medical records are often the only source of the truth. They are likely to be far more reliable than memory.

The management and preservation of the hospital records in Indian context present a very gloomy picture. Despite the intensive effort at national and international level, the fundamental health care needs of the population of the developing countries are still unmet. The lack of basic health data renders difficulties in formulating and applying a rational for the allocation of limited resources that are available for patient care and disease prevention.

It is recommended that more efforts should be made by the institutions/hospital managements, all clinicians and medical record officer to improve the standard of maintenance and preservation of medical records. In this article, we are discussing the various aspects of the medical record management.

Objectives of Maintaining Medical Records

Monitoring of the actual patient

Medical research

Medical/dental or paramedical education

For insurance cases, personal injury suits, workmen’s compensation case, criminal cases, and will cases

For malpractice suits

For medical audit and statistical studies

Altering Medical Records

While writing the medical notes, as far as possible do not overwrite. If the change is needed, strike the whole sentence. Do not leave ambiguity. Make a habit of signing if change is made. Preferably put the date and time below the signature. Attempting to obliterate the erroneous entry by applying the whitener or scratching through the entry in such a way that the person cannot determine what was written originally written raises the suspicion of someone looking for negligent or inappropriate care.

Do not alter the notes retrospectively. If something written was inaccurate, misleading or incomplete then insert an additional note as a correction.

Entries in a medical record should be made on every line. Skipping lines leave the room for tampering with the records.

Amend on electric record by striking through rather than deleting and overwriting the original entry. After inserting the new note, add date, time and doctor name.

Correction of the personal identification data of the patient like name, age, father/husband name, and address should only be made on the basis of affidavit attested by notary or 1st class magistrate.

Who has Access to Medical Records?

Medical records are the property of the hospital or patient’s medical practitioner. It is a confidential communication of the patient and cannot be released without his permission.

All patients have right to access their records and obtain copy of those records.

Patient’s legal representative has the right to those records as long as patient has signed a release of records to accompany any request from the legal representative.

Other health care providers have the right to the records of the patient, if they are directly involved in the care and treatment of the patient.

Parents of a minor also have access to patient’s medical records.

Medical records are usually summoned in a court of law in certain cases like-road traffic accident, medical negligence, insurance claim etc.

The impersonal documents have been used for research purposes as the identity of the patient is not revealed. Though the identity is not revealed, the research team is privy to patient records and a cause of concern about the confidentiality of the information. Recently a need has been felt to regulate the need of medical research, effectively restricting the manner in which this type of research is conducting. An ethical review is required for using the patient’s data.

Hard Copy Only

Computers are now widely used in institution/hospitals for electronic patient records but still hard copy is required for following documents [1]

Consent need to be on hard copy.

Referral to doctor need hard copy.

Police case need hard copy.

Certificate of fitness should be on hard copy