Preserving History is a Responsibility - Medical Records

Preserving History is a Responsibility - Medical Records

Ever been irritated by a patient for losing their medical records?
Here’s something you should know.

[1] As per the law, preserving Medical Records of patient is a responsibility of the healthcare professional and healthcare establishments.

[2] Medical Records of every patient needs to stored, including those of patients only seen in the Out Patient Clinic.

[3] All medical records need to be stored for a minimum period of 3 years.

[4] Medical records of cases which have been registered as a Medicolegal case (MLC) have to be stored for a minimum period of 10 years

[5] Medical records of a case, which has an ongoing legal battle, for malpractice or otherwise, need to be preserved indefinitely.

[6] The doctor/hospital has to keep a record of all medical certificates issued by them.

[7] If the medical records were handed over to the patient, and no copy was stored with the doctor/hospital, it amounts to deficiency on the part of the doctor/hospital.

[8] Digitisation of all medical records has not been made mandatory by any law as of today, but is strongly recommended by several regulations.

[9] Digitisation of medical records does not necessitate moving to completely digital softwares, but can be simple methods like storing scanned copies of medical records.

[10] As we move towards a Digital India, It is likely that digitisation of medical records may be made mandatory in the forthcoming laws and regulations.

So the next time you are seeing a patient in the OPD, remember that even that prescription is a medical record, and needs to be stored.

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