"Testimony based on recorded facts is given as greater consideration than testimony dependent on memory".
Medical record (MR) is systematic documentation of sequential events of patients' medical history and healthcare. The existence of MR dates back to emperor Ashoka's time when individual physician developed a practice of keeping records. Western world (USA and European nations) is practising MR keeping since last 200 years; in our country in spite of tremendous advances in medical audit, accreditation and medical insurance systems in private and public sector the MR keeping is still in nascent stage.
Healthcare services are already under Consumer Protection Act and case histories have unquestionable legal importance. In case of accusation, the most important evidence deciding doctor's sentence or acquittal will be within the case history, that is why it is said that case history can be doctor's best allied; but also doctor's worst enemy. Other than safeguarding physician, MR keeping services should be the basis for planning patients’ healthcare, document may serve as educative material and provide data for research work.
Confidentially of, any MR is a professional obligation for the treating physician or team as such. The secrecy could only be divulged if (a) patient authorises disclosure, (b) court order to reveal, (c) broader public interest is at stake.
National Health Policy (NHP), 2002 states that "In an attempt at consolidating the data base and graduating from a mere estimation of the annual health expenditure, NHP-2002 emphasises the need to establish national health accounts".
Regarding MR Medical Council states that : (a) A registered medical practitioner shall maintain a register of medical certificates giving full details of certificates issued with signature of patients and with at least one identification mark. (b) To maintain an MR pertaining to his / her indoor patients for a period of 3 years from the date of commencement of treatment. (c) Routine case records should be preserved up to 6 years after completion of treatment and up to 3 years after the death of the patients. (d) Where there is a chance of litigation arising for medical purpose of negligence, record should be preserved for at least 25 years specially in case of minors. (e) Medicolegally important record should be preserved up to 10 years after which they can be destroyed after making index and summary of the case. (f) There are certain records of hospital which are of public interest and are transferred to public record library after 50 years for release to public and those involve confidentiality of the individuals are released only after 100 years.
International classification of diseases (ICD) code is orginally developed to classify and code mortality data as from death certificates, now been expanded as clinical modification (ICD-CM) which has come to be used for morbidity data in a broad range of setting, such as inpatient and outpatient clinic records, physician’s offices record and other research surveys.
There is a clear evidence of serious quality of care deficiency in healthcare delivery in our country. The problem ranges from inadequate and inappropriate treatments, excessive use of higher technology or wasting of available scarce sources in both public and private sectors. Remedy to this melody is joint action by 2 lac members of IMA to keep appropriate MR assemble the data, and guide the authority to plan appropriate healthcare at national, state and local levels.