Medical Records Chapter Notes | Forensic Medicine and Toxicology (FMT) - NEET PG PDF Download

Introduction

Medical records consist of various documents that outline the care and treatment provided to a patient. They serve as the only reliable source of information about the patient for healthcare professionals, whether they are general practitioners or hospital staff, regardless of whether the service is private or public.

All healthcare professionals are obligated to maintain medical records for patients they see as outpatients or for those admitted to the hospital. These records are not only essential for ensuring proper medical care but may also be required as legal evidence. Consequently, medical records contain vital information such as:

• Patient's identity
• Type of treatment received
• Location of treatment
• Date of treatment
• Other relevant medical details

Typically, hospitals have a specialized department with trained staff responsible for managing these records. This department is commonly known as the Medical Record Department (MRD).

Contents of Medical Records

Medical records should include the following information:

• Patient Particulars: Include the patient's name, age, sex, address, the person who brought them to the hospital, and the referring physician.
• Dates and Times: Record the date and time of the patient's arrival, examination, admission, and discharge from the hospital.
• Current Complaints: Document the patient's complaints at the time of arrival.
• Past Medical History: Include relevant details from the patient's past medical history.
• Family History: Provide relevant information from the patient's family history.
• Personal History: Include relevant details from the patient's personal history.
• Physical Examination: Detail the findings from the physical examination conducted by the physician.
• Laboratory and Investigative Reports: Include reports of laboratory tests and other investigations, such as blood tests and X-rays.
• Treatment Provided: Document the treatment administered to the patient.
• Consent Forms: Include signed consent forms for each procedure and operation performed.
• Prognosis Chart: Maintain a prognosis chart.
• Specialist Consultations: Record details of any cross consultations or referrals to other specialists, including their opinions and reports.
• Discharge Condition: At the time of discharge, record the patient's condition.
• Discharge Summary: Prepare a discharge card with a summary of admission details, investigations, treatments, and follow-up advice. If referred by a family physician, send a copy of the discharge instructions to them.
• Discharge Against Medical Advice: If applicable, document discharges against medical advice and obtain signatures from the patient and/or their guardian.
• Police Intimation Letter: Include a copy of the Police Intimation Letter in specific medicolegal cases.
• Death Documentation: In cases of death, record the cause, date, and time of death.
• Doctor's Information: Include the name, signature, address, and medical council registration number or license of the attending doctor.

In Medical Cases

• In medical cases, there are specific precautions that need to be followed in addition to the usual procedures:
• The casualty Medical Officer (MO) must ensure that all registers are numbered and properly certified.
• Every page of the record should be serially numbered.
• On all pages, laboratory reports, and X-ray plates, the term MLC (Medico-Legal Case) must be marked. This includes requisitions for laboratory tests and X-rays as well.
• All entries should be accurate, detailed, and in sequential order.
• Avoid using abbreviations.
• Any corrections made must be initialed.
• All medicolegal documents need to be prepared in duplicate.
• Communications with the police must be in written form, and copies should be attached to the case files.
• Hospitals should adhere to local regulations regarding the retention and destruction of medicolegal case records.
• All records must be kept secure, under lock and key.
• Entries in hospital papers should include the signature and name of the responsible doctor.

Property Rights of Medical Records

Medical records and X-ray films are the property of the hospital. Patients pay for medical services and treatment, but they do not own the records or X-ray images created by the hospital. These records are kept at the hospital for the benefit of the patient, doctor, and hospital. While patients do not own their records, they have the legal right to access the information contained within them.

Rights of Patients

• Patients typically receive copies of their investigation reports, treatment recommendations, and discharge summaries.
• Patients have the right to know the details in their records and can obtain a copy of their hospital record upon discharge, subject to reproduction costs.
• In the case of a deceased patient, their next of kin can access the hospital records.
• Doctors have the discretion to withhold records if they believe that providing access could harm the patient.
• Hospitals and doctors cannot use a patient’s records for publication purposes without obtaining the patient’s consent.

Medical Records in Court

• Hospitals and doctors are required to provide case records when called to court.
• Medical records may be requested by the court for various criminal cases, including assault, burns, criminal abortion, dowry deaths, injury, murder, poisoning, rape, suicide, and vehicle accidents.
• In civil cases such as workers’ compensation, insurance claims, malpractice/negligence suits, contested wills, and disputed paternity cases, the court may also require medical records.
• Information about a patient’s health shared with the courts is considered privileged communication, protecting doctors from breaching confidentiality.
• Before submitting case files to the court, hospitals should make photocopies of every page, as the court often retains the records.
• If the court needs to keep the documents, hospital doctors should request a receipt indicating the total number of pages held by the court.

Submission of Records to Government and Other Agencies

• Government agencies, such as the LIC, may request information about patients treated in hospitals.
• By law, these agencies cannot access this information without the patient's written consent.
• The hospital should not comply with such requests without consent.
• However, basic details may be disclosed if allowed by law, including:
  • Name
  • Age
  • Sex
  • Date of admission
  • Date of discharge

Storage and Disposal of Medical Records

The storage and disposal of medical records is a crucial concern for hospitals. With the advent of computers, managing these records has become more efficient. Data can now be entered into computers and stored conveniently in files or on CDs using a CD writer. These digital documents can be kept indefinitely, as CDs occupy less space compared to physical copies. However, certain guidelines are typically followed for different types of cases:

Non-medicolegal Cases (Non-MLC)

• OPD records must be retained for a minimum of 3 years. After this period, they can be destroyed unless there are legal or medical reasons to keep them.
• IPD records should be kept for at least 5 years.

Medicolegal Cases (MLC)

• There is no defined time limit for these records. Therefore, they cannot be destroyed and must be available whenever needed.

Medical Records and Research

• Medical records cannot be shared with researchers without obtaining prior written consent from the patient.
• Additionally, approval from the hospital's ethics committee is required before sharing such information.