Sunday, June 15, 2008

MAINTENANCE OF MEDICAL RECORDS

*The records should be kept under lock and key, in the custody of the doctor concerned or may be kept in a Central Record Room, in hospitals where such facility is available; as per the institution’s rules.
*Most hospitals have a policy of maintaining all medico-legal records [MLR’s] for variable periods. However, as per law, there is no specified time limit after which the MLR’s can be destroyed. Hence, they have to be preserved permanently.
*In view of the multitude of cases against the doctors under the Consumer Protection Act, it is advisable to preserve all the in-patient records for a period of at least 5 years and OPD records for 3 years.
*The Medical Council of India has given the following recommendations in context of medical and medico-legal records and their maintenance:
- 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 performa laid down by the Medical Council of India [available at http://www.mciindia.org/]
- If any request is made for medical records either by the patient/authorized attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within a period of 72 hours.
- 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 certificate or report.

2 comments:

DR R ASOKAN said...

it is quite clear about the in patient records, but do we have any guidelines for maintaining out patient records. should we keep a copy of the prescription that we issue, if so for how long. what are the other legal requirements in running a private pediatric office practice

DR R ASOKAN said...

KINDLY ENLIGHTEN ME ABOUT THE LEGAL REQUIREMENTS FOR RUNNING A PEDIATRIC OFFICE PRACTICE, WHAT RECORDS SHOULD I MAINTAIN FOR OP PATIENTS