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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
 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
 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.
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, X-
ray, Ultrasound, CT scan, MRI including
photographs etc. have to be clearly documented
and the original reports to be made available.
3. The general informed consent for routine
treatment in OPD, inpatient, investigations, minor
surgical procedures, treatments should be
obtained from the 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.
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
6. The policies and procedures laid out have to
meticulously followed to safe guard the
doctors/nurses from any legal actions.
 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.