Chapter 9: Medical Records

The ________ must ensure that all the registers are numbered and duly certified.

Comprise various documentary references of the care and treatment particulars provided to the patient.

Information about the health of a patient given to the law courts is covered under privileged communication and the doctor is immune to the charges of breaking ________ under such circumstances.

It is the only valid data available regarding the patient treated by the health care professional, either as a general practitioner or as a hospital-based medical officer, irrespective of whether private or government origin.

It is mandatory that all healthcare professional should maintain the medical records of the patient examined/and treated by them on outpatient basis or as an inpatient case admitted in the hospital.

It encompasses routinely the who, what, where and when of the patient care in the hospital.

The OPD records have to be preserved for a minimum of 3 years, when they can be destroyed.

The IPD records have to be preserved for a minimum of 5 years.

There is no specified time limit and hence they cannot be destroyed and must be made available as and when needed.