by Dr. (Prof.) Mahesh Baldwa,
M.D,D.C.H, FIAP, MBA, LL.B,LL.M , Ph. D(law)
SENIOR PEDIATRICIAN & MEDICOLEGAL ADVISOR
Formerly Assistant Professor of Pediatrics at T.N. Medical College and Nair Hospital, Mumbai-400008
Ex. Asst. Professor JJ Hosp, Grant medical college
Ex.Professor, paper setter & examiner of law to postgraduate students of University Department of Law, University of Mumbai
Baldwa Hospital, Sumer Nagar,S.V. Road,
Borivali (West)Mumbai 400 092
Cell 09322990138
Q what is the peculiarity about medical records?
A: Patients and doctors may forget but records will always remember. Records are admitted as evidence to court of law. The written records produce evidence irrefutable in court of law.
Q: why records are best defense against litigation?
Medical records are our best defense against allegations of negligence, deficiency of service and unfair trade practice and medical malpractice. But Records should be transparent, correct, clear, comprehensive, chronological manner written with use of contemporaneous method of abbreviations so the accountability becomes apparently clear.
Q: why records improve quality medical care?
A: quality improvement can be done by review of hospital records. Good quality records are desirable because of their importance in clinical management of patients and value in professional evaluation of quality care, decreasing morbidity and mortality.
Q: what does medical record includes?
A: Following is purported to be exhaustive list of various records yet it may vary from case to case
- Outdoor case paper / register / booklet /card/ letterhead/loose prescription sheet/chit
- Under treatment certificate/sick certificate / fitness certificate
- Referral to other doctor /pathology lab/ x-ray / Sonography / CAT/ MRI
- Record of Informed consent with patient name, name of procedure/surgery/anesthesia, date, place, duly signed and witnessed
- Is consent required for giving injections / immunization/internal examination like PV examination of breasts and PR ? routinely NO but presence of relative in the room is required, it does not mean the relative has to supervise doctor. Presence of female attendant is must for examination of females.
- In case of known allergy or hypersensitivity or specific contraindications in patient administration of injections need test dose and consent
- Allergy to egg protein or neurological disorder children may require consent for immunizations.
Q: what constitutes reasonably good Records of Indoor case paper?
A: good IPD records should have one or more of following qualities:
- Chronological order of progress of disease and treatment given
- Monitoring of vitals, Minimum pulse, BP, RR and Temp. In patients with diabetes monitoring of blood sugar levels, CAD serial ECG’s or continuous monitoring
- Pathological test, when ordered and what are the positive findings to be recorded on case paper
- X-Ray, Sonography with report, when ordered and what is the positive finding on case paper
- Pre invasive procedure or pre-operative treatment or preparation, which is usually aimed at avoiding vagal shock averted by inj Atropine, aspiration during anesthesia averted by NBM, Ranitidine, Inj Metaclopramide
- Details of invasive procedure or surgery or anesthesia given
- Post procedure or post operative treatment
- Date wise record of investigations be it radiological, pathological or reports of CAT or MRI or any other opinion of specialist or consultant
- Record includes record of refusal of treatment or investigation or surgery
- PM doctors give Postmortem notes
Q: What are the common problems of record retention?
A: following are common problems of record retention:
- Customarily patient retains OPD records
In India outpatient records, vast majority of doctors, write the history, clinical findings, and positive finding in investigation reports on letter heads and hand over to the patient.
- Customarily patient retains investigation and imaging records
Reports of blood, stool urine and imaging investigation are retained by patient party in original.
Q: What are the Storage problems of OPD records?
A: No doubt if all OPD patients’ records are retained by doctor then it shall create shortage of storage space in doctor’s clinic if maintained in physical form. The solution is to maintain records in electronic format. It is allowed as evidence under section 65 B of Indian Evidence Act as well as Information Technology Acts.
Q: What are the disadvantages of using conventional paper-based medical records?
A: The conventional paper-based medical record has several limitations. The limitations are
- tracking down patients and
- coordinating healthcare process
- indexing
- illegible
- Errors and fragmentation.
- Accessible to only one person at a time.
Q: What are the reasons, explanations for Loss of OPD record?
A: customarily retention of OPD records by patients. Practically it is observed that a majority of patients, when asked for their records (especially after some length of time), they will very casually inform you that they have has lost the papers. This is what happens to your painstakingly taken history and physical findings written on OPD case papers. The standard explanations are: paper lost from in rickshaw, taxi, motorcar, bus. OPD case papers are also lost in shifting of residence and eaten by rats. More sophisticated patients will give more plausible replies. But the fact of the matter is that very few patients place a value on the medical records and may not produce them when required, so that the very purpose of using them for future treatment is defeated. This is the non-medico legal dimension of parting with the records, which is helpful to a litigant doctor.
Q: How records are best defense in medico legal cases?
A: remember medical records are our best defense when we have to reply to allegations against us. We have to give more importance to OPD records. If the choice is between the patient and you having the records, it is better for you to have the records. If both can have them, it is ideal. EMR or electronic medical record keeping is a also good option. And finally, as always, better to be safe than to be sorry in maintaining proper records.
Q: How Long To Maintain Records?
A: following are the time limits for Maintaining Records:
- Ideally records of adult patients are maintained for 3 years and children, for 21 years. (3+18 years). Mentally retarded forever till the person is practicing.
- From Income tax point of view for seven years
- As per code of medical ethics April 2002 for 3 years
Q: How to destroy records?
A: following are the guidelines to destroy records:
- Give a public notice in one English and one vernacular newspaper, with a time limit of usually one month from date of publication in which any one wants the relevant paper can come and take a copy of record needed.
- After one month destroy record for every one save and except,
- Where litigation is going on
- Pre-litigation process of notice exchange is going on
- Mentally ill or retarded patients
- Where you expect that there could be future trouble.
- After one month destroy record for every one save and except,
Q: How should destroy the hard copy of paper records?
A: The only safe methods for destroying paper records are incineration or shredding and should not be given to RADDIWALA. A destruction method for electronic medical records is by electronic method.
Q: Where can medical records be stored?
A: Inactive records may be separated from the active patient cases and stored outside the office premises. Take the following safety majors into consideration when making arrangements for long-term storage by outsiders:
Privacy— will the records be protected from unauthorized persons?
Safety— will the records be protected from fire or flood damage and unauthorized access or theft?
Accessibility—will the records be easy to retrieve and copy?
Q: When to avoid electronic format of record keeping?
A: avoid electronic format of record keeping in following situations
- Frequent monitoring of vitals parameters and investigations on heat labile paper.
- Document Moribund patient
- Document complications of disease, drug, surgery, anesthesia or procedure
- Document if Patient suddenly take a serious turn
- Document Patient’s transfer to other hospitals/doctors
- Document for police Accident / suicide / attempted homicide /poisoning/ burns /fracture / tetanus and cases involving violence causing disease or injury
Q:when hard copy of records is essential in medico legal point of view?
A: In following situations hard copy of records is essential
- Consent needs to be on hard copy
- Transfer to other hospital needs hard copy
- Referral to doctor / investigations need hard copy
- Police cases need hard copy
- Certificate of leave / sick certificate /fitness certificate needs hard copy
- All registers needed by various authorities like birth, death, MTP,PNDT, tubal ligation / vasectomy registers, Indoor admission, Outdoor registers, police information, OT registers, sterilization of registers /autoclave registers/ notifiable disease / Nursing /order book or register, bill books etc need hard copy
- Highlight Risks and warnings – This is vital information which the physician is to be made aware of quickly. These need to be highlighted before seeing or treating the patient; for example, allergies, and drug sensitivities or high risk medical conditions. This should also include legal status of the patient. An important risk would also be history of violent tendencies, HIV status or known abuser of health care services.
Q: Which records need to be kept ready for inspection always?
A: Following are the records need be kept ready for inspection always :
- Degree certificates,
- MMC/MCIM Registration,
- approvals, licenses,
- Nursing home
- Shop establishment registration etc.
- biomedical waste act,
- MTP act,
- PNDT act,
- spirit licence,
- Narcotic drugs licence etc.
Q: Which records are to be kept in duplicate?
A: Following are the records need be kept in duplicate
- Patients that are referred to other doctors with signature of patient/rep.
- Patients that are transferred to other hospitals with signature of patient/rep.
- Information to police / MLC cases with signature of patient
Q: Which eventualities are covered by keeping duplicate records?
A: Following are covered by keeping duplicate records
- Patient alleging that he kept on taking treatment to overcome the legal limitation clause for time bar.
- Some case papers of particular date are not annexed with complaint to suit allegations.
- Allegations that investigations, referral to doctor, transfer or MLC case registration was not done
Q: Who has a legal right to retain medical documents?
A: This is a vexed question and needs to be addressed. But generally OPD records are customarily held by patient and IPD records are customarily retained by doctor. Does a physician or a hospital have the right to retain documents that contain information relating to the patient? There is one view, which holds that since information contained in a document is privileged the physician/hospital has the right to retain such document. A contrary view holds that the information, for future reference should be given when specifically sought. It is submitted that information, though privileged, is about the patient who seeks the document. The same cannot be withheld since there cannot be a privilege against a person who seeks information about him contained in a document. A physician or hospital may retain a photocopy of the document given to the patient Alternately; the patient could be supplied with a photocopy of the document sought while retaining the original with the physician/hospital. A similar approach should be adopted regarding X-ray plates and other information about a patient. A physician/hospital is bound to disclose information when ordered by a court or agencies concerned in the administration of justice. In Bombay High court decision in Radhyeshyam Raheja v. Maharastra Medical council that the patient should be supplied with required Xeroxed documents at reasonable charge.
Q: Is information stored in other formats, such as videos, x-ray films, ECGs, fetal monitor strips, and photos, part of the medical record?
A: Yes. Regardless of format, any and all data collected at the time of a patient encounter is part of the medical/legal document.
Q: How long should billing records, telephone calls/messages, and appointment registers be kept?
A: The Doctors Company recommends the following:
- Billing records in all states should be retained for seven years according to Internal Revenue Service standards. They may be kept in a separate file.
- Telephone calls that pertain to medical care should be documented in the medical record and kept according to the above medical record retention guidelines.
- Appointment register may be kept for 3 year.
Q: Can records be transferred to microfilm or disk or stored in a computer?
A: Yes. The factors in the previous question can also guide you on transferring records to microfilm or disk and on storing records in a computer. Protected health information (PHI) transferred or stored electronically must be encrypted. Computer data should be backed up at regular intervals and stored off site, as in the previous question.
Q: Is it sufficient to back up a copy of an electronic health record (EHR) onto a disk?
A: Yes. However, you should store a copy of the EHR software, along with the data itself, to make sure the records can be read in the future. Alternatively, you could save the data in PDF format so it can be read without special software. Regardless, all PHI stored electronically must be encrypted.
Q: If a patient requests original record, can I hand over the original record?
A: No. The original is the property of the physician, who has a duty to maintain the record.
Q: If someone claiming to be a representative of a deceased patient’s estate requests a copy of the chart, what should I do?
A: You must verify that the individual is a authorized representative of the decedent’s estate (for example, heir, the executor etc). The individual should provide a copy of an official document prove his claim of heir, the executor.
Q: can physician Disclose data for secondary purposes like research, from TPA managers, private companies providing risk management services.
A: yes, but permission of patient by special consent is required
Q: who should Retain IPD health records in original?
A: doctors should be keep IPD records in original.
Q: how to “record” and “maintain” medical records pertaining to “visual and audio recordings” of patients?
A: yes, but permission of patient by special consent is required
- Recordings made as part of a patient’s care
- Recordings made for research, teaching, training and other healthcare-related purposes
- Recordings for use in widely accessible public media (television, radio, internet, print)
- Telephone and other audio recordings
- Making recordings covertly
- Deceased patients
- Storing and disposing of recordings
Q: is doctor obliged to give records under right to information Act 2005?
A: private doctor is not covered by right to information Act 2005; doctors in public sector must seek the permission/special consent of the patient before giving records under right to information Act 2005
Q: Why should doctor use EMR Software?
A: Electronic medical record software can help you effectively maintain your medical records. Using EMR software can help you effectively overcome the disadvantages of the conventional paper-based method. EMR software can be accessed by many at the same time. EMR software eliminates errors, fragmentation and wrong indexing. It is permitted by 65 B of Indian evidence act.
Q: What are the advantages of using EMR software?
- The EMR software enables the input, storage, transfer and the retrieval of medical information within a practice and enables the interfacing with other data providers outside the practice.
- Using the EMR software can result in financial benefits such as, savings on transcription, recording and proof reading.
- The electronic medical records software enables healthcare physicians to spend their time with patients without wasting time on transcription.
- The PDA interface of the EMR software enables the doctor to capture super bill details for hospital visits, ensuring that no billing information for a patient is lost. This feature also enables the doctor to track appointments while on the move.
- The electronic medical record solution can effectively use the charts database to optimize claim documentations, thereby ensuring higher returns for each claim.
- The EMR software solution can be integrated with different insurance providers.
- The electronic medical record software has built-in integration points with other financial and ERP/products.
Q: What makes the EMR software different?
- The EMR software can effectively handle and manage large practices and healthcare centers
- The EMR software can proficiently addresses the main needs of a hospital information system, since it is a knowledge based system
- The electronic medical record software can incorporate all the departments of a practice
- The EMR software can provide 24x7access to comprehensive information across the enterprise
- The EMR software can competently perform medical billing functions
- Using the EMR software can help you reduce errors
Q: What are the characteristic features of EMR software?
A: The electronic medical record software usually has the following characteristic features.
- The EMR software can competently address issues regarding security, confidentiality and privacy
- The EMR software can store data according to the related regulation acts
- The EMR software is cost-effective and easy to use. You can also save on time and effort by using EMR software. The EMR software can be easily merged into your existing processes without any hassles
- The EMR software can efficiently store, transfer and retrieve medical information within a practice.
Q: Will EMR software be able to enhance the functionality of a practice?
A: Yes. The EMR software can increase and improve your efficiency as it has an electronic patient check-in. The EMR software can also be effectively used to access any records on a 24×7 basis.
Q: How can the EMR software benefit my healthcare organization?
A: By employing the use of the EMR software at your hospital you can benefit from the following.
- doctor/hospital can experience accurate and error-free coding with the help of the coding functions and templates in the EMR software
- Your patients can easily access the results of their tests
- Paperless records
Q: What are some of the modules in the EMR software?
A: The following are some of the modules in the EMR software.
- Appointment Scheduling Module
- Medical Billing Module
- Messaging Module
- Archiving Module
- Drug Interaction Module
- Fax/Scanner Integration Module
- Reports Module
