The medical record serves as the central repository for planning patient care. It documents communication among patient and health care provider and professionals contributing to the patient's care. The traditional medical record for inpatient care can include admission notes, on-service notes, progress notes, preoperative notes, operative notes, postoperative notes, procedure notes, delivery notes, postpartum notes, and discharge notes. Another main purpose of the medical record is to ensure documentation of compliance with institutional, professional or legal regulation.
Electronic health or medical record is a legal document evidence (as per the Indian Evidence Act, 1872). It is a comprehensive view of the patient's health history, clinical findings that have been collated over time and is more of a comprehensive collection of medical data. Many consider the information in medical records to be sensitive personal information covered by expectations of privacy, many ethical and legal issues are implicated in their maintenance, such as third-party access and appropriate storage and disposal. Although the storage equipment for medical records generally is the property of the health care provider, the actual record is considered in most jurisdictions to be the property of the patient, who may obtain copies upon request.The terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction. The medical record includes a variety of types of "notes" entered over time by health care professionals, recording observations and administration of drugs and therapies, orders for the administration of drugs and therapies, test results, x-rays, reports, etc. The maintenance of complete and accurate medical records is a requirement of health care providers and is generally enforced as a licensing or certification prerequisite.
Retention and Destruction of Medical Records
In India there are no clear cut guidelines or law regarding the same, though allowing access to the patient's records is mandated in accreditation standards like the NABH. However, as per good practice, the patient files are stored for a periodic term as follows:
• OPD records 5 years
• IPD records 7 years
• Medico-legal cases: 15 years
All medical records can be destroyed after the mentioned time. However as a good practice, the hospitals publish an advertisement in the news papers for the concerned to take claim of their records
A properly designed template requires at least one physician narrative which is a few sentences of prose composed totally by the physician with no IT automation involved. A medical record shall be maintained for every individual who is evaluated or treated as an inpatient, outpatient, emergency patient, ambulatory clinical practice patient or dental patient. Currently, the medical record is considered a hybrid record, consisting of both electronic and paper documentation. The transition to electronic records represents a significant change to the clinical process in medical practice. These changes must be carefully considered to ensure patient safety and quality of care throughout the transition process. It will be through the integration of medical records and clinical processes. It must ensure patient privacy and information security. The medical record contents can be maintained in either paper (hardcopy) or electronic formats, including digital images, and can include patient identifiable source information, such as photographs, films, digital images and fetal monitoring strips and /or a written or dictated summary or interpretation of findings. The current electronic components of the medical record consist of patient information from multiple electronic health record source systems. The intent is to integrate all electronic documents into a permanent legal health record repository. Original medical record documentation must be sent to the designated Health Information.
From a legal standpoint it is easy to read through the facade of clinical detail and completeness of management received in event of medical litigation
Dr Imtiaz Ahmed Wani is Surgeon Specialist, DHS, Kashmir