10 September 2013 13:29
Samuel Abraham & Kamalini, Legal Officers, CMC
Vellore, give an overview on the importance of maintaining medical records to
enhance healthcare delivery, and the ways and means to do it right
|
|
|
D Samuel Abraham
|
Modern communication systems and advanced
technology have become a part and parcel of all the healthcare sectors and
medical records are not an exception to this. Medical records are the who,
what, where, when and how of the patient/s. Medical records act as a means of
communication and it is an easy reference for continuity of care.
Document >Record
A document becomes a record when that particular
document is archived. A document can be archived at any time but once a
document is archived then no further changes can be made to it.
Ownership
Medical records are considered to be the physical
property of the facility. Regulations regarding access to medical records vary
depending on state law. The fact that the facility owns the paper upon which
the particulars/information are written does not prevent others from submitting
legitimate claims to see and copy the information therein.
Preservation of records
Neither uniform policy nor definite guidelines has
been evolved as to the time limit for the preservation of records. Under the
Limitation Act, maximum of three years is allowed for filing a case. In the
earlier days, charts of the patients were maintained for nearly 25 years. But
now, the Health and Family Welfare Department of certain states have given
specific time duration for maintenance and preservation of medical records.
They are:
- Non medico legal IP 3 years
- Medico legal IP and death cases 6 years
- Master case sheet in speciality hospital 20 years
- Scientific and research oriented IP 12 years
- Paediatric medico legal IP records, death case 12 years
Electronic medical records and its validity
Electronic medical records are an evolving concept
defined as 'a systematic collection of health information about individual
patients in electronic form. It is a record in digital format that is capable
of being shared across different health care settings, by being embedded in
network-connected enterprise-wide information system.'
After the enactment of the Information Technology
Act, 2000 and subsequent amendment in the Information Technology (Amendment)
Act, 2008, any records in electronic form can be produced before any authority
as a valid proof. Appropriate amendments were also carried out in Sec. 3 of the
Indian Evidence Act, 1872. The electronic records are acceptable evidence in
the Court of Law.
Protection of medical records
Medical records are the life blood of healthcare
delivery system and a complete medical record should describe all aspects of
patient care. There are greater possibilities of misuse of medical records. So,
there is a need to restrict access at the same time it should serve legitimate
purpose only. The place of access and the time of access play a vital role in
use of electronic records.
|
Functional comparison – paper record vs
electronic record
|
||
|
Function
|
Paper based record
|
Electronic record
|
|
Availability
|
One location
|
Multiple
|
|
Cost
|
High
|
Low
|
|
Data
|
Difficult to extract
|
Easy to extract
|
|
Durability
|
Low
|
High
|
|
Duplication of records
|
Possible
|
Not-possible
|
|
Security
|
Low
|
High
|
|
Audit Trial
|
No
|
Yes
|
|
Practitioner
|
Freedom
|
Restricted
|
Other role of medical records
In addition to helping the medical professionals in
assessing the health condition of the patient, medical records provide a major
role in defending the institution against possible litigation. The “FORM
System” may be used in the arrangement of medical records.
F - Forming data’s in
O - Order or proper arrangements of
R - Required way of
M - Management
O - Order or proper arrangements of
R - Required way of
M - Management
The medical records also provide a helping hand to
do research:
- To evaluate the performance of health professionals.
- To evaluate the use of the institution’s resources such as special
diagnostic equipment and services offered by the facility.
- To evaluate the care which the institution provides for certifying
and accrediting purposes.
RTI and medical records
With the advent of Right To Information (RTI) Act,
the role of medical records has gained paramount importance. The demands for
information in medical records are increasing rapidly. The personnel who are
in-charge of the medical records should be well versed with the provisions of
RTI Act so that he/she will be able to know whether the request for information
should be provided or not.
The request for information from the third-party
about a patient does not come under the definition of 'information' provided
under Sec. 2 (f) of the RTI Act. This is because there is a contractual
relationship between the Hospital and the patient and the concept of privity of
contract comes to play. All the information requested through RTI need not be
disclosed. Sec. 8 of the RTI Act, 2005 provides certain exemptions from
disclosure of information:
“The information available to a person in his
fiduciary relationship need not be disclosed unless, the competent authority is
satisfied that the larger public interest warrants the disclosure of such
information.” (Sec. 8 (e) - RTI Act, 2005)
“The information which relates to personal
information the disclosure of which has no relationship to any public activity
or interest, or which would cause unwarranted invasion of the privacy of the
individual need not be disclosed unless the Central Public Information Officer
or the State Public Information Officer or the appellate authority, as the case
may be, is satisfied that the larger public interest justifies the disclosure
of such information.” (Sec. 8 (j) – RTI Act, 2005)
Digital signature
Digital signature enables the subscriber to
authenticate his electronic record. It cryptographically binds an electronic
identity to an electronic document and the digital signature cannot be copied
to another document. Digital signature can be a good replacement for
traditional system of ink signature and can be used widely.
Conclusion
Hospitals all over the globe are swiftly moving
from paper to paperless. The transformation to electronic health record is an
advocated and accepted philosophy which can provide swift, safe, high
qualitative care with reasonable cost to the patient care. By gone would be the
days when voluminous papers charts are carried in hand-driven trolleys from
Medical Records Department to various clinical areas and back to congested
corridors of hospital! The voluminous medical records are at a distance of a
click in his personal computer of a medical professional and next second he can
visualise the minute details of a particular patient.
No comments:
Post a Comment