HEALTH AND LAW
Medical
records
K Mathiharan
Well-maintained medical records will unquestionably
help doctors and hospitals in their defence in cases of medical
negligence.
In Md. Aslam v. Ideal Nursing Home (1), the
State Commission made a strong note of the lack of regulations governing nursing
homes and made suggestions regarding medical record-keeping. In Poona Medical
Foundation Ruby Hall Clinic v. Marutirao L. Titkare (2), the National
Commission held that not providing medical records did not constitute negligence
or deficiency in service, as there was no legal duty cast to furnish such
documents to a patient. It further held that no material was placed before the
Commission to show that either by law, or by convention or by practice, was
there any obligation on the part of the hospital to furnish to the patient full
particulars of the surgical operation performed on him.
In January 1996, the Bombay High Court (3)
held that doctors and hospitals should make medical records available to
patients or their near relatives on demand, after levying an appropriate fee. It
further held that doctors and hospitals could not claim any secrecy or
confidentiality in the matter of copies of the case papers relating to the
patient.
The Indian Medical Council (Professional conduct,
Etiquette and Ethics) Regulations, 2002 (4) states that every physician
shall maintain the medical records pertaining to his/her indoor patients for a
period of three years from the date of commencement of the treatment. If any
request is made for medical records either by the patients/authorised attendant
or legal authorities involved, the documents shall be issued within a period of
72 hours and refusal to do so would be misconduct.
In many countries, the doctors or hospitals that
ask for the tests are the owners of the X-ray films and other investigational
and case records. A patient can get a copy of it only when he/she is referred to
another doctor or decides to file a suit against the doctor/hospital. In the UK
to overcome the doctors' concern and to maintain patients' confidentiality the
following Acts are in force.
According to the Data Protection Act, 1984, an
individual should be informed by anyone holding computerised information whether
that information includes his/her personal data and should be supplied with
copies of it. The Access to Medical Reports Act, 1988 states that insurers and
employers may not be shown a report until the patient has seen and commented on
it and has consented to its disclosure. According to the Access to Health
Records Act, 1990 patients have access to their health records.
Manipulated medical records, failure to deliver
X-ray films and statement of accounts of a hospital, and improperly maintained
medical records were considered deficient services by the Consumer Disputes
Redressal Agencies.
- In Nihal Kaur v. Director, PGI, Chandigarh
(5), the State Commission held negligence on the basis of the records,
which seemed to be manipulated.
- In V P Shanta v. Cosmopolitan Hospitals (P) Ltd (6), the State
Commission held that failure to deliver
X-ray films is deficient service.
The patient and his attendants were deprived of their right to be informed of
the nature of injury sustained. - In Force v. M Ganeswara Rao (7), the State Commission held that
there was negligence as the case sheet did not contain a proper history,
history of prior treatment and investigations, and even the consent papers
were missing.
- In Dr C Venkatasamy, Director, Aravind Eye Hospital v. N Mariappan,
(8) the hospital rendered free treatment to a patient in an eye camp and
claimed that he did not come under the Consumer Protection Act. When the
complainant petitioned for summoning the statement of accounts, the hospital
refused to part with it and filed a Revision Petition.
References
1. Orissa SCDRC 1994 (1)
CPR 619.
2. NCDRC 1995 (1) CPJ 232: 1995 (1) CPR 661 (NCDRC) 1996 CCJ
70.
3. Raghunath G. Raheja v. Maharastra Medical Council (198 Bom AIR
1996).
4. In Section 1.3 Subsections 1.3.1 and 1.3.2.
5. 1996
(3) CPJ 112 (Chandigarh (U.T.) CDRC).
6. 1997 (1) CPR 377 (Kerala
SCDRC).
7. 1998 (3) CPR 251; 1998 (1) CPJ 413 (AP SCDRC).
8.
Tamil Nadu State Consumer Disputes Redressal Commission in order
R.P.No.15/1998 dated 18/10/2002.
K MATHIHARAN, Advisor, Institute Of Legal Medicine,
New No. 53, Fifth Street, Padmanaba Nagar, Adyar, Chennai 600 020. Email:
Legalmedicine@Vsnl.Com
