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MEDICAL RECORD FOR DOCTORS :

Importance of maintaining records in medical profession need not to be over-emphasized. Most of the doctors are fully aware that records are a must for medico-legal and income-tax purpose. In addition to these reasons, records have assumed more importance and significance because of application of Consumer Protection Act to medical profession. However, doctors because of their busy schedule,, either don't maintain records of keep very brief, incomplete, cryptic records which are of no use in court matters. With the number of consumer cases against doctors increasing very rapidly, doctors should take all precautions for their defense and one of the most important defense tool is a detailed record of each and every patient.

1) Outdoor Patient's Daily Register

This is a must for all doctor's whether family physicians or consultants. The table give below is self explanatory
Day :
Date :
Sr. No. Time of arrival Name of patient Age & Sex Case Paper or file No. Services rendered Fees received Receipt No.
Additional information like general condition of patient whether critical, under influence of alcohol, rowdy behaviour etc. should be noted

2) Family Register/File/Computer

In addition to daily register of out-door patients, it is advisable to maintain family Register of each family. Doctor can maintain a register or a seperate file for each family. If a doctor is having a computer the information can be fed in the computer. The register/file or computer should include following information :-

Name of Head of the family.
Age, Sex. Occupation and Income.
Business of Office Address with Telephone Numbers. if any.
Residential Address with Tel. No., if any
Family Member's information as follows.

3) Indoor Patient's Register

Time of admission is very important. In a recent case decided by National Commission, a patient had claimed that though he was admitted at 2p.m. he was not treated till 3.15 p.m. However, he could not substantiate his claim.

4) Indoor Patient's File

Case papers right from the day of admission. The first case paper should have information like patient's name, age, sex, occupation, address, tel. nos., date and time of admission, provisional diagnosis, condition of patient etc. If patient is critical obtain relative's signature on case paper

All examinations carried out and positive findings
Investigations carried out and their report
Date and Time of daily check-up. If patient is critical, doctor visits the patient three, four or even more times daily. All such visits & timings & findings should be clearly mentioned.

5) Certificates

Certificates are required to be issued for various purposes like sickness, physical fitness, medico-legal cases, death certificates etc. Following points should be remembered before issuing certificates :

A complete record of patient's name, age, sex, diagnosis, treatment, investigations advised, referrals, if any duration of treatment should be maintained. The certificates issued should be correct in all such respects.

Date of issue, nature of illness, duration of treatment should be clearly mentioned in the certificates.

Patient should be thoroughly examined before giving certificate.

It is advisable to issue illness certificate and fitness certificate separately. Proforma is given at the end of the article.

6)Information to Police

IT is moral and legal duty of a doctor to inform police (and keep record of the same) in following cases :-

Suspected homicide.
Unnatural deaths like drowning.
Road accidents and emergencies.
Suicide attempts.
Operation Theatre deaths If patient dies withint 24 hours of admission in hospital. Death of women from burns, drowning, poisoning, injuries in less than 7 years of marriage.

7)Referrals

If a patient is referred to another doctor or hospital it is advisable to keep a carbon copy of your reference letter, more particularly, in medico-legal cases. Name, age, sex of the patient, date and time of consulting, positive findings, treatment given should be mentioned in reference note. Patient's or relative's signature should be obtained on carbon copy.

8) Investigations

Patient is usually referred for investigations like Pathology, Radiology, Sonography, CT Scan etc. on printed reference books provided by the concerned consultant. However, all the details like investigations advised and name of the Pathologist / Radiologist etc. should be mentioned in your records.

9) Consent

Consent is a must for various procedures and operations. It a patient dies after operation, doctor can be charged for murder if consent has not been obtained. If, however, doctor obtains consent before operation and in case patient dies after operation, doctor will not be charged in criminal court. This does not mean that consent gives blanket immunity to the doctor.

10) Receipts

Recipes are very important for court as well as income-tax purposes. Receipt book should be printed, should have serial numbers and be in duplicate. No false receipts should be issued to satisfy greed of unscrupulous money - makers

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