It is obligatory for hospitals to provide copy of the case record to patient or his legal representative: IMA New Delhi, March 25, 2016: Not many are aware of is that it is obligatory for doctors, hospitals to provide the copy of the case record or medical record to the patient or his legal representative. With an aim of raising awareness, IMA educated its 2.5-lakh members about the rights of patients and the laws that govern the area. Public health information was also released. The preamble to the Constitution of India coupled with the Directive Principles of State Policy strives to provide a welfare State with socialist patterns of society. It enjoins the State to make the “improvement of public health” a primary responsibility. Furthermore, Articles 38, 42, 43 and 47 of the Constitution provide for promotion of health of individuals as well as health care. The Constitution of India also enumerates the separate and shared legislative powers of Parliament and State Legislatures in three separate lists: the Union List, the State List and the Concurrent List. The Parliament and State legislatures share authority over matters on the Concurrent List, which include criminal law and procedure. Consumer Protection Act is another legislation, which is aimed at preventing negligence and deficient services besides assuring right to information about medical treatment given to the patient at the threat of imposing compensation. The Medical Council of India has imposed an obligation on Hospitals as per the regulations notified on 11th March 2002, amended up to December 2010 to maintain the medical record and provide patient access to it. According to them every physician shall maintain the medical records pertaining to his/her indoor patients for a period of three years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. Speaking about the same, Dr SS Agarwal – President IMA and Dr KK Aggarwal – Honorary Secretary General IMA said, “Every patient has a right to claim medical records pertaining to his treatment and the hospitals are under obligation to maintain them and provide them to the patient on request.As per the MCI ethics regulations, not giving records can amount to professional misconduct.” For how long should the records of patients be maintained? • As per the proposed / draft “Clinical Establishments (Registration and Regulation) Rules, 2010, “Copies of all records and statistics shall be kept with the clinical establishment concerned for at least 3 or 5 years or in accordance with any other relevant Act in force at the time”. • 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”. • As per Rule 6F (3) of the Income Tax Rules, 1962, doctors in private practice are required to preserve the daily case register as per Form 3C for a period of six years from the end of the relevant assessment year. That would ordinarily mean for seven years from the close of the accounting year. • As per Punjab Medical Manual (1934), the medicolegal record is to be preserved for 12 years. • As per the DGHS vide letter No. 10-3/68-MH dated 31-8-68, records should be maintained 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”. In summary, medical records belong to the medical professionals / entities but patients generally have a right to review them, demand copies of them, and to demand their confidentiality as per the MCI ethics regulations.