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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
ABSTRACT:
It is very important for the health care organization to properly document the
management of a patient under their care. Medical record keeping has evolved
into a science of itself. This will be the only way for the doctor to prove that the
treatment was carried out properly. Moreover, it will also be of immense help in
the scientific evaluation and review of patient management issues. Medical
records form an important part of the management of a patient. It is important
for the doctors and medical establishments to properly maintain the records of
patients for two important reasons. The first one is that it will help them in the
scientific evaluation of their patient profile, helping in analyzing the treatment
results, and to plan treatment protocols. It also helps in planning governmental
strategies for future medical care. But of equal importance in the present setting
is in the issue of alleged medical negligence. The legal system relies mainly on
documentary evidence in a situation where medical negligence is alleged by the
patient or the relatives. In an accusation of negligence, this is very often the
most important evidence deciding on the sentencing or acquittal of the doctor.
With the increasing use of medical insurance for treatment, the insurance
companies also require proper record keeping to prove the patient's demand for
medical expenses. Improper record keeping can result in declining medical
claims. It is wise to remember that “Poor records mean poor defense, no records
mean no defense”. Medical records include a variety of documentation of
patient's history, clinical findings, diagnostic test results, preoperative care,
operation notes, post-operative care, and daily notes of a patient's progress and
medications. A properly obtained consent will go a long way in proving that the
procedures were conducted with the concurrence of the patient. A properly
written operative note can protect a surgeon in case of alleged negligence due to
operative complications. It is important that the prescription for drugs should be
legible with the name of the patient, date, and the signature of the doctor. An
undated prescription can land a doctor in trouble if the patient misuses it.
Medical recording needs the concerted effort of a number of people involved in
patient care.
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
The doctor is the prime person who has to oversee this process and is primarily
responsible for history, physical examination, treatment plans, operative
records, consent forms, medications used, referral papers, discharge records,
and medical certificates. There should be proper recording of nursing care,
laboratory data, reports of diagnostic evaluations, pharmacy records, and billing
processes. This means that the paramedical and nursing staff also should be
trained in proper maintenance of patient records.
METHODS OF RECORD KEEPING
The traditional method of keeping records that is followed in our establishment
is the manual & electronically method involving papers and books. The
computerization of medical records that are neat and tidy, and can be easily
stored and retrieved. If it is demanded during court proceedings, it is the duty of
the hospital and the doctor to prove that these computer documents were not
altered. Another major concern is maintaining confidentiality of the patient
records as the patient can hold the doctor and the hospital negligent for breaking
confidentiality of his medical records.
CONFIDENTIALITY OF MEDICAL RECORDS
Medical records can be used as a personal or impersonal document.
1) Personal document - this information is confidential and should not be
released without the consent of the patient except in some specific situations.
2) Impersonal document – the record loses its identity as a personal document
and patient permission is not required. These records could be used for research
purposes.
Confidentiality is an important component of the rights of the patient. The
hospital is legally bound to maintain the confidentiality of the personal medical
records. The patient can claim negligence against the hospital or the doctor for a
breach of confidentiality. However, there are certain situations where it is legal
for the authorities to give patient information. They are as follows:
1) During referral,
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
2) When demanded by the court or by the police on a written requisition,
3) When demanded by insurance companies as provided by the Insurance Act
when the patient has relinquished his rights on taking the insurance.
4) When required for specific provisions of Workmen's Compensation cases,
Consumer Protection cases, or for Income tax authorities. The maintenance of
confidentiality is an important issue in the era of electronic data storage. There
should be checks in place so that only those who are authorized can access the
patient data.
The impersonal documents have been used for research purposes as the identity
of the patient is not revealed. Though the identity of the patient is not revealed,
the research team is privy to patient records and a cause of concern about the
confidentiality of information.
Maintaining confidentiality, integrity and security of information.
The records are kept under lock and key room in the custody of MRD in charge.
The following persons have the access to key and authorization for sending
records for storage and final destruction.
1. Medical Director
2. Admin Manager
3. General Manager
4. Medical record in charge,
5. TPA in charge.
6. Quality Manager
The medical records are stored properly in the storeroom on different shelves.
There is arrangement of fire extinguisher to prevent any fire and also pest
control is done at regular intervals to prevent destruction of medical records.
Procedure to ensure confidentiality, security and integrity of data:
The Medical Record is a private document related to the patient history and
treatment both in a physical and electronic format and should not be disclosed
as it breaches the Code of Medical Ethics.
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
No part of the information contained in the MR should be reproduced in any
format by any individual who is handling the contents or details of the patient
record without the consent of the management and the patient concerned unless
otherwise needed for any case of subpoena or any other legal proceedings the
information may be presented before the actual trial of cases without the
consent of the patient.
Only on written consent / authorization from the patient / legal heirs and an
authorization from the management can the information be released to any
external individual. The access to the Records by the visiting doctors should be
provided once the doctor has been referred by the main treating doctor;
No record will be issued to any authority after discharge of patient after then
hospital staff authorized by management, with a requisition duly signed by
authority along with a photo I.D. and approval from MD, the same is than kept
with original record of the patients for future reference.
CATEGORIES OF MEDICAL RECORDS
The different categories of medical records are as follows:
Certain records must be given to the patient as a matter of right. Discharge
summary, referral notes, and death summary in case of natural death are
important documents for the patient. Hence, these have to be given without
charge for all including patients who leave against medical advice. The hospital
bill cannot be tied up with these sensitive documents that are necessary for
continuing patient care. Thus, the above documents cannot be legally refused
even when the hospital bill has not been paid.
Certain records may be issued after the patient or authorized attendant fulfills
the due requirements as stipulated by a hospital. This requires a formal
application to the hospital requesting for the records. It is necessary that the
hospital bills are cleared and the necessary processing fee has been paid. The
documents in this group include copies of inpatient files, records of diagnostic
tests, operation notes, videos, medical certificates, and duplicate copies for lost
documents. It is important that the duplicate copies should be marked
appropriately. It is not unusual for an unscrupulous patient to use it for multiple
insurance claims without the knowledge of the establishment.
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
Certain records cannot be given to patients without the direction of the Court.
The outpatient file, inpatient file, and files of medico-legal cases including
autopsy reports cannot be handed over to the patient or relatives without the
Direction of the Court. But if these medico-legal cases are being referred to
another center for management, copies of records could be given. However, X-
rays are given only after a written undertaking by the patient or relatives that
these will be produced in the Court as and when required.
MEDICAL COUNCIL OF INDIA GUIDELINES ON MEDICAL RECORDS
The issue of medical record keeping has been addressed in the Medical Council
of India Regulations 2002 guidelines answering many questions regarding
medical records. The important issues that have been addressed are as follows:
Maintain indoor records for 3 years from commencement of treatment (Section
1.3.1).
Request for medical records by patient or authorized attendant should be
acknowledged and documents issued within 72 hours (Section 1.3.2).
Maintain a register of certificates with the full details of medical certificates
issued with at least one identification mark of the patient and his signature
(Section 1.3.3).
Efforts should be made to computerize medical records for quick retrieval
(Section 1.3.4).
HOW LONG MEDICAL RECORDS SHOULD BE PRESERVED?
There are no definite guidelines in India regarding how long to retain medical
records. The hospitals follow their own pattern retaining the records for varied
periods of time. Under the provisions of the Limitation Act 1963 and Section
24A of the Consumer Protection Act 1986, which dictates the time within which
a complaint has to be filed.
In our establishment we maintain the entire Outpatient case sheets for a period
of 2 years after the last visit made by the patient. All the Inpatient case sheets
shall be maintained for a period of 3 years after the last visit made by the
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
patient. The MLC case sheets shall be retained for 15 years or till the final
judgment from the Court. The records which have crossed the retention period
shall be selected and destroyed as per procedure.
For Birth & Death Case sheets should be retained for Lifetime.
Review:
Medical records shall be reviewed. Review shall be done taking samples as per
statistical table depending upon the population (No. of files generated during the
month). The selection of samples shall contain both active and discharged
patients. The review shall be done by Quality coordinators for the timeliness,
legibility and completeness of the medical records in the IP Op patient files.
Deficiencies: A report shall be prepared for the deficiencies observed during
review process; the observed deficiencies shall be analyzed for the root cause
and corrective action and preventive action shall be identified; the corrective
and preventive action shall include if necessary to check entire population of
files of the month to regularize the records.
Disposal and destruction of medical records:
The systematic permanent destruction of medical records that have been
maintained for the prescribed retention period is the overall responsibility of
medical record department.
The purpose of destruction is to permanently remove records from active use,
with no possibility of reconstructing the information.
Medical record that is scheduled for destruction must be placed in a secure
location to guard against unauthorized or inappropriate access until the
destruction takes place.
Maintain a record destruction log, individually listing all medical records (i.e.
individual patient records) to be destroyed. That log book should include
following information:
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Issued By: Rev. No. : 00
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TATA MOTORS HOSPITAL CHAPTER NAME: COP
PROCEDURE FOR RETENTION & DESTRUCTION Document No: TMH/IMS/QSP/02
MEDICAL RECORDS
Patient name
Registration no. & INP. No.
Date of admission
Date of discharge
Date of destruction
Medical director shall sign and approve in the record destruction log before
destruction.
Advertisement should be given in all leading newspaper regarding the
destruction mentioning the time period & date of destruction
Destruction will do through shredding under supervision of Medical Director
Shredding will be done in an approved location by approved agency.
Approved By: Quality System Procedure Issue No. : 01
Issued By: Rev. No. : 00
Issue Date: Rev. Date:
