Medical records are a fundamental part of a doctor’s duties in providing patient care. As well as handwritten clinical notes, medical records include emails, scanned records, consent forms, text messages, verbal correspondence between health professionals, laboratory results, X ray films, photographs, video and audio recording, and any printouts from monitoring equipment.

The records form a permanent account of a patient’s illness. Their clarity and accuracy is paramount for effective communication between healthcare professionals and patients. The maintenance of good medical records ensures that a patient’s assessed needs are met comprehensively.

Good Documentation - Good Defense, Bad Documentation - Bad Defense, No Documentation - No Defense:

Poor record keeping is a major factor in litigation cases brought against healthcare professionals. When patients seek legal advice—for example, in cases of malpractice allegations—the attorney’s first task is to review the patient’s notes and determine whether any injuries were caused by negligence. Good medical record the best defense against any accusation of medical negligence. From a litigation point of view, even if everything was done correctly at the time of an incident, if it has not been documented, it has not been done. This makes even the best of doctors difficult to defend.

When recording medical information, remember to keep it simple, and be mindful that the quality of the case record is assumed to reflect the quality of care delivered. Write down what you said, what you did, what you were told, and what you observed. Spending 15 minutes writing an accurate and detailed note can save a huge amount of time 15 years later.In India Registered Medical Practitioners are bound by various laws to retain medical records of patients they treat.

 The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 mandates about maintenance of Medical record-

01. 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 Performa laid down by the Medical Council of India 

02. If any request is made for medical records either by the patients / authorized attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

03. A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall-

              A) Always enter the identification marks of the patient

             B)  Shall keep a copy of the certificate.

             C)  He / She shall not omit to record the signature and/or thumb mark,

Section 1.9 of the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 mentions that the physician shall observe the laws of the country in regulating the practice of medicine and shall also not assist others to evade such laws. He should be cooperative in observance and enforcement of sanitary laws and regulations in the interest of public health. A physician should observe the provisions of the state acts like-

 Drugs and Cosmetics Act, 1940;

 Pharmacy Act, 1948;

Narcotic Drugs and Psychotropic substances Act, 1985;

 Medical Termination of Pregnancy Act, 1971;

Transplantation of Human Organ Act, 1994;

  Mental Health Act, 1987;

 Environmental Protection Act, 1986;

Pre–natal Sex Determination Test Act, 1994;

Drugs and Magic Remedies (Objectionable Advertisement) Act, 1954;

Persons with Disabilities (Equal Opportunities and Full Participation) Act, 1995

Bio - Medical Waste (Management and Handling) Rules, 1998

 and such other Acts and Rules, Regulations made by the Central/State Governments or local Administrative Bodies or any other relevant Act relating to the protection and promotion of public health.

In compliance to many of the laws mentioned above a Physician is required to retain medical record for variable duration.

                                                                                     (Compilation:Dr Gaurav Aggrawal,Medicolegal Expert & Lawyer)