Thursday 10 February 2011

How long to preserve medical records?

How long to preserve medical records?
QUESTION—A patient was operated in 2003. A claim against the doctor has been made in 2011. How long should medical records be preserved?
ANSWER—
1—The consumer can file a complaint till 2 years after the service was provided. This is usually extended to mean—“Till 2 years after the defect in service comes to notice”. Courts can condone delay.

2—Records should be kept as follows:

A—Under MCI Regulations, 2002, applicable to doctors (not to hospitals)—
As per Regulation 1.3.1 of the Indian Medical Council (Professional conduct, Etiquette and Ethics) Regulations, 2002, “Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3”.

B—Under the DGHS guidelines, applicable to central government hospitals—

The guidelines for the government hospitals have been published by the DGHS vide letter No. 10-3/68-MH dated 31-8-68 as follows:

For inpatient medical records (case sheets)……………….10 years
For medico-legal registers…………………………………….10 years
For outpatient records………………………………………….5 years

The above requirement can be found in the “Hospital Manual” published in 2002 by the Directorate General of Health Services, MOHFW, GOI, in chapter 12 titled “Medical Record Services”.

C—Under other Acts applicable in the state concerned (such as the respective Clinical Establishments Act, Nursing Home Act etc.)—As per the provisions of the Act concerned.

---M C Gupta
MD (Medicine), LL.M.
Fellow: National Foundation of Clinical Forensic Medicine
Ex-Professor and Dean
Practicing advocate
mcgupta44@gmail.com
18 January 2011

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