Medical records are often at the center of disputes between the patient and the doctor and/or the hospital.
While hospitals or healthcare establishments own the physical (or electronic) records, they are only “held in trust by them on behalf of the patient”. The information or data contained therein is owned by the patient. Without the consent of the patient, no action on their health record can be taken.
Hence, it is obligatory for doctors and hospitals to provide the copy of the case record or medical record to the patient or his legal representative. Accurate and complete records should be maintained and their safety and privacy should be ensured.
The National Human Rights Commission has recognized this right of the patient and has included “Right to records and reports” in its charter of patient rights.
The Right to Records and Reports is as follows:
“Every patient or his caregiver has the right to access originals / copies of case papers, indoor patient records, investigation reports (during period of admission, preferably within 24 hours and after discharge, within 72 hours). This may be made available wherever applicable after paying appropriate fees for photocopying or allowed to be photocopied by patients at their cost.
The relatives / caregivers of the patient have a right to get discharge summary or in case of death, death summary along with original copies of investigations. The hospital management has a duty to provide these records and reports and to instruct the responsible hospital staff to ensure provision of the same are strictly followed without fail.”
· Annexure 8 of standards for Hospital level 1 by National Clinical Establishments Council set up as per Clinical Establishment Act 2010
· MCI Code of Ethics section1.3.2
· Central Information Commission judgment, Nisha Priya Bhatia Vs. Institute of HB&AS, GNCTD, 2014
· The Consumer Protection Act, 1986
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA
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