Failure to provide medical records to patients on proper demand will amount to deficiency in service and negligence. Medical records are acceptable as per Section 3 of the Indian Evidence Act, amended in in a court of law. These are considered useful evidence by the courts as it is accepted that documentation of facts during the course of treatment of a patient is genuine and unbiased. Medical Records that are written after the discharge or death of a patient do not have any legal value.
Erasing of entries is not permitted and is questionable in Court. In the event of correction, the entire line should be scored and rewritten with the date and time. Criminal cases for proving the nature, timing, and gravity of the injuries.
It is considered important evidence to corroborate the nature of the weapon used and the cause of death. Medical negligence cases- these can be in criminal courts when the charge against the doctor is for criminal negligence or under the Consumer Protection Act for deficiency in the doctor's or hospital's care.
It is usual to summon a doctor to appear in court to testify and to bring all the medical documents. When the court issues summons for medical records, it has to be honored and respected as it is a constitutional obligation to assist in the administration of justice.
The records can also be produced in court by the medical records officer of the hospital. If the doctor is required to be present for giving evidence based on the medical records, he has to be present in the court to give evidence. The court may require these documents to be submitted for which a record is issued by the court. However, if the records are required for continuation of the medical treatment of the patient, copies can be kept by the hospital.
There have been many judicial decisions pertaining to medical records from various courts in India and a review of some of the important ones is given in this section. The National Commission had held that there was no question of negligence for failure to supply the medical records to patients unless there is a legal duty on the hospital to give the records.
The alleged hospital had provided a detailed discharge summary to the patient. The hospital and doctor were guilty of deficiency in service as case records were not produced before the court to refute the allegation of a lack of standard care. The opposite party was found negligent as he should have retained the case records until the disposal of the complaint.
Not producing medical records to the patient prevents the complainant from seeking an expert opinion. It is the duty of the person in possession of the medical records to produce it in the court and adverse inference could be drawn for not producing the records. The State Commission held that failure to deliver X-ray films is deficient service. The patient and his attendants were deprived of their right to be informed of the nature of injury sustained.
The allegation of not informing the possibility of vocal cord palsy was negated by the detailed written consent that showed that it was explained properly and consented.
The allegation of tampering with the operation notes was negated by the State Commission in a case of intraoperative death as the complainant could not prove the allegation.
The hospital was held vicariously liable for the negligent action of the doctor on the basis of the bill showing the professional fees of the doctor and the discharge certificate under the letterhead of the hospital signed by the doctor. There were two progress cards about the same patient on two separate papers that were produced in court.
Not maintaining confidentiality of patient information can be an issue of medical negligence. The HIV status of a patient was known to others without the consent of the patient. Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Indian J Urol v. Indian J Urol. Joseph Thomas. Author information Copyright and License information Disclaimer. For correspondence: Dr.
E-mail: ni. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This article has been cited by other articles in PMC. Abstract It is very important for the treating doctor to properly document the management of a patient under his care. Keywords: Medical records, medical negligence. Discharge notes This is a crucial piece of evidence regarding the inpatient treatment of a patient.
Referral notes Referral notes are an important component of patient records. The important issues that have been addressed are as follows: Maintain indoor records in a standard proforma for 3 years from commencement of treatment Section 1. Medical records are usually summoned in a court of law in the following cases: Criminal cases for proving the nature, timing, and gravity of the injuries.
It is considered important evidence to corroborate the nature of the weapon used and the cause of death Road traffic accident cases under the MACT Act for deciding on the amount of compensation Labor courts in relation to the Workmen's Compensation Act Insurance claims to prove the duration of illness and the cause of death Medical negligence cases- these can be in criminal courts when the charge against the doctor is for criminal negligence or under the Consumer Protection Act for deficiency in the doctor's or hospital's care It is usual to summon a doctor to appear in court to testify and to bring all the medical documents.
Poona Medical Foundation v Marutturao Tikare. Bombay: Kanaiyalal Ramanlal Trivedi v Dr. Satyanarayan Vishwakarma. CPJ Bhopal. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya. Force v. M Ganeswara Rao. V P Shanta v. Cosmopolitan Hospitals P Ltd. Devendra Kantilal Nayak v Dr. Kalyaniben Dhruv Shah. Ismail v K. Nihal Kaur v. Director, PGI, Chandigarh. You should contact your or your child's previous health care provider, the last school you or your child attended, the New York State Department of Health, or your local county health department for your immunization records.
Our immunization records do not replace individual or parent-maintained immunization records, such as the Lifetime Health Record. You and your provider should continue to use this record if you have it. Health Search all NYC. Menu Promoting and Protecting the City's Health.
Vaccine Records. To request a vaccination record: Visit My Vaccine Record. To learn how to access records, click on the "Accessing Records tab. You can now use your mobile phone number, email address or IDNYC number to search for your immunization record online. If it's dental information, get in touch with your dentist's office. If it's a general health issue, you'll probably want to talk to your family doctor.
When it comes to asking for medical records, different health care providers have different ways of doing things. Some might ask you to fill out an authorization form. If so, you'll want to be ready with information like this:.
A health care provider's office might charge a fee to cover the cost of having someone make copies. You'll probably have to pay mailing costs to have the records sent to you or another doctor if you won't pick them up in person. Be sure you understand what's included in your request for medical records. If you check "all records," you'll end up with crates and crates of paper and expense! Some offices offer an "abstract" with the last few years of office visit notes. That way, only the most recent, relevant information is compiled and sent.
The law gives health care providers up to 30 days to provide copies of medical records. But almost all health care organizations supply records much faster than that.
Most people get their non-critical care records within 5 to 10 business days. If records are needed faster — like when a patient needs medical treatment — the health care provider holding the records usually releases them right away. If you need to get records for non-emergency situations like switching to a new doctor , it's best to give lots of notice. Let the medical provider who has your records know that you'd like copies a few weeks ahead of any visits with your new health care provider.
Health care providers can say no to requests for records — but it almost never happens. When it does, it's because a doctor's office is trying to protect a patient's privacy or safety. For example, they may say no to sharing information if they're not sure the person asking for the records has a right to see them.
Or they may not release records if they think it will lead to a patient being harmed. If health care providers deny access to records, they must give the reasons why in writing within 30 days.
If any request for medical information is denied, a patient has the right to ask for the decision to be reviewed again. If you notice something missing or think something is wrong in your medical records, you have the right to ask for a correction. Your doctor's office will explain how they handle changes to your records and what you need to do to request a change.
The law gives health care providers 60 days to make a change or deny the request. Parents have access to their kid's medical records until the child is However, many states now leave it up to doctors to decide if they tell parents some information — like about sex or drug use, for example. The law also states that parents can no longer see a teen's medical records if they've agreed the child can see a doctor confidentially. Most hospitals or doctors make every effort to protect patients' privacy when it comes to the sensitive information in their medical records.
Sometimes a health care provider will feel that it's not in a teen's best interest to give information to parents, even when a child is younger than For mental health records like the notes a therapist takes during counseling sessions the age when parents no longer have access to a child's medical records is 15 or 16, depending on the state.
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