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Legal Aspects of Medical Records

Legal Aspects of Medical Records

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Published by neeta rajesh bhide
LEGAL ASPECTS OF MEDICAL RECORDS

Mrs. Neeta Rajesh Bhide
M.Sc. N.



The medical record is the who, what, why where and when of patient care in the hospital. With the advancement in medical knowledge and complexity of modern medical and surgical treatment exisitng in hospital today, an accurate and adequate medical record is essential as documentary reference of the care and treatment which the patient received in the hospital.



McGibony has said “ A chronicle of the pageantry of medical
LEGAL ASPECTS OF MEDICAL RECORDS

Mrs. Neeta Rajesh Bhide
M.Sc. N.



The medical record is the who, what, why where and when of patient care in the hospital. With the advancement in medical knowledge and complexity of modern medical and surgical treatment exisitng in hospital today, an accurate and adequate medical record is essential as documentary reference of the care and treatment which the patient received in the hospital.



McGibony has said “ A chronicle of the pageantry of medical

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Published by: neeta rajesh bhide on Aug 09, 2010
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LEGAL ASPECTS OF MEDICAL RECORDS

Mrs. Neeta Rajesh Bhide
M.Sc. N.

The medical record is the who, what, why where and when of patient care in the hospital. With the advancement in medical knowledge and complexity of modern medical and surgical treatment exisitng in hospital today, an accurate and adequate medical record is essential as documentary reference of the care and treatment which the patient received in the hospital.

McGibony has said “ A chronicle of the pageantry of medical and scientific progress is found in the hospital records. There may be found the running story, disconnected, it is true, of the drama, the comedy, the mystery, the miracles of medicines and hospitals of twentieth century.

Each medical record reveals information, always centered around a patient (who may be a man woman or a child). The patient is recipient of the medical care, which is offered to him/her by a team which usually consists of the doctor, the nurse, and the paramedical worker. This care is offered by the team to the recipient (patient) in a particular location, this being the hospital. All activities by the team in this location are for the benefit of the patient and this is recorded, thus making the existence of the hospital medical record possible.

The hospital compiles and keeps medical records primarily for the benefit of the patient, and the protection of the hospital and physician. However, the personal data contained therein, considered as confidential communication, is a property interest of the patient. In addition to being kept for the benefit of the patient, medical record is also kept as a guide to consultants, for the education of undergraduates and postgraduates, for the training of nurses, medical statistics research and the protection of the physician, hospital staff and hospital against unjust criticism.

When the hospital admits a patient, it enters into an implied contract to render services necessary in the care and

treatment of the patient. This necessitates
keeping a chronological record of the care and treatment rendered by the personnel.


(a) Confidential Communication Medico-legal Problems Personal or impersonal document.

Hospital medical records can be documentary evidence as per the Indian Evidence Act, 1872 as amended upto August 01, 1952, 1961 and medical records are generally subpoenaed to court in the following type of cases:
• Insurance Cases • Workmen’s Compensation Cases • Personal Injury Suits • Malpractice Suits • Will Cases • The Income Tax Act • Certificate of Birth & Death • Criminal Cases

CONSUMER PROTECTION ACT

Since 1986, the consumer protection act came into existence the health care providers including doctors, nurses, paramedics and hospital administrators have to be meticulously careful in understanding the full responsibilities that they have to fulfill in the legal and administrative sense. This becomes imperative to ensure whatever the services rendered have to be properly documented in patient records to safe guard the staff involved in the consumer service. After enacting the consumer protection law, innumerable negligence cases have resulted, which earlier would have been surfaced.

DOCUMENTATION OF THE MEDICAL RECORDS
1. Each and every patient record must contain complete and accurate patient identification data history, physical examination conducted, progress notes, nurses notes, investigations carried out, diagnosis, consultations, treatment including medications, therapy, medical, surgical procedures and end results. 2. In the course of treatment, necessary investigation reports carried out, including lab, Xray, Ultrasound, CT scan, MRI including photographs etc. have to be clearly documented and the original reports to be made available.

DOCUMENTATION OF THE MEDICAL RECORDS
3. The general informed consent for routine be

treatment in OPD, inpatient, investigations, minor
surgical obtained procedures, from the treatments should patient/authorized patient

attendant by the medical record staff/nurse. 4.A special informed consent has to be obtained by the concern surgeon before performing and surgical procedures.

DOCUMENTATION OF THE MEDICAL RECORDS
5. The attending/treating physicians are responsible

to ensure that the documentation of the pertinent
information have to be recorded comprehensively and promptly to justify the diagnosis treatment,

and end results, which in turn will protect doctor
and the health institutions from any legal litigations. 6. The policies and procedures laid out have to meticulously followed to safe guard the doctors/nurses from any legal actions.

THE INDIAN PENAL CODE, 1860

There is a criminal prosecution prescribed under Section 304-A of the Indian Penal Code , 1860 for causing death by negligence. It says –
Whoever causes the death of any person by
doing any rash or negligent act not amounting to culpable homicide, shall be punished with

imprisonment of either description for a term
which may extend to two years, or with fine, or with both.

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