In my earlier article, I had enumerated the legal provisions in India that deal with medical record-keeping. It is pertinent to note that there are provisions in Clinical Establishment Act (CEA), Directorate General Health Services guidelines (2002) and Income Tax Rules for mandatory maintenance of out-patient (OPD) case records. If we take into consideration the provisions of Consumer Protection Act, 1986 and the Limitations Act, 1963, it is clear that in those States where the duration of keeping OPD-records has not been specified, it is advisable to preserve OPD records for at least 2 years. As per Income Tax Rules, the OPD case register needs to be preserved for 7 years. As per CEA applicable in the respective State, the duration of preservation of OPD case records varies from 3 to 5 years.
While most doctors are now acquainted with the importance of record-keeping for in-patient (IPD) cases, the importance of keeping records for OPD cases is still largely unrealised. The Aravind Eye Hospital Vs Minor Kanmani case (verdict in 2011), which was decided by the Puducherry UT Consumer Disputes Redressal Forum, is an excellent example which reaffirms the importance of accurate OPD record-keeping and its issuance to patients. In this case, the Opthalmologist had examined a child and correctly diagnosed presence of caterpillar-hair in the conjunctiva of left eye. He removed the caterpillar hair, applied antibiotic ointment, bandaged the eye and asked the patient to follow-up the next-day. Subsequently, the patient followed-up with the doctor, but developed corneal edema, anterior chamber exudates, vitritis , retinal detachment and loss of vision. The Puducherry UT Consumer Disputes Redressal Forum held the doctor guilty on two counts - (i) Not doing a slit-lamp examination at the first visit, and (ii) Not issuing a detailed OPD note to the patient describing the diagnosis, investigations, treatment and instructions for follow-up, which is generally a norm in most hospitals.
Thus, not issuing a note to OPD patients mentioning the details of examination, diagnosis, investigations, follow-up instructions and prescription of medications, is considered as "deficiency in service". With changing times and increasing patient awareness, doctors are best advised to maintain OPD case records with due diligence, and, more importantly, issue examination / treatment details to patients as well.
I have started this blog as an effort towards helping doctors understand the legal importance of small things which make a big difference. In my subsequent articles, I will discuss many such small but important things which doctors can do to ensure a safe and relatively stress-free clinical practice.
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