Doctors, give all records to patients or pay damages!

Hospitals, whether private or public, cannot refuse to furnish the records of treatment to the patient. They should also understand that refusal amounts to deficiency and hence ‘negligence’. If they come up with plea that medical records were removed or destroyed, the courts or consumer fora can draw adverse inference, that entitles patients for damages from doctors or hospitals.

The Kerala High Court recognised the principle of patient’s right to be informed in Rajappan Vs. Sree Chitra Tirunal Institute for Medical Science and Technology (ILR 2004 (2) Kerala150). The Court had observed that:

".....Appendix 3 referred to in MCI regulations 1.3.1 provides for information, among other things, pertaining to diagnosis, investigations advised with reports, diagnosis after investigation, and advice. Therefore it is obvious from the appendix that what is to be given is the full details about the patient, namely, the findings pertaining to the deceased.

That is the diagnosis and the periodical advice for treatment. As and when diagnosis is made the treatment will be advised by the doctor to the nursing staff in the case sheet itself. Therefore the case sheet will show the progressive testing, diagnosis and treatment given to the patient. The details to be furnished in Appendix 3 are of comprehensive in nature and should contain the diagnosis and treatment given to the patient during the period, the patient was under treatment.

Regulation 1.3.1 has to be read with regulation 1.3.2 which makes it mandatory that any patient requesting for medical records should be furnished copies of "documents" within 72 hours from the date of demand. In other words, the patient's right to receive documents pertaining to his/her treatment is recognised by the Regulations.

The documents referred to in Regulation 1.3.2 necessarily have to be the entire case sheet maintained in the hospital, which contains the result of diagnosis and treatment administered, the summary of which is provided in Appendix 3. Therefore the petitioner is entitled to photocopies of the entire case sheet and the respondents cannot decline to give the same by stating that the details are available in Appendix 3 furnished, which they are willing to furnish."

The Kerala High Court has further explained:
“It is also to be noticed that Regulations do not provide any immunity for any medical record to be retained by any medical practitioner of the hospital from being given to the patient. On the other hand it is expressly provided that a patient should be given medical records in Appendix 3 with supporting documents.

Therefore in the absence of any immunity either under the Regulations or under any other law, the respondent­ Hospital is bound to give photocopies of the entire documents of the patient. Standing counsel for the respondent­Hospital submitted that the documents once furnished will be used as evidence against the hospital and against the doctors concerned. I do not think this apprehension will justify for claiming immunity against furnishing the documents.

If proper service was rendered in the course of treatment, I see no reason why the hospital, or staff, or doctors should be apprehensive of any litigation. A patient or victim's relative is entitled to know whether proper medical care was rendered to the patient entrusted with the hospital, which will be revealed from case sheet and medical records.

There should be absolute transparency with regard to the treatment of a patient and a patient or victim's relative is entitled to get copies of medical records. This is recognized by the Medical Council Regulations and therefore petitioner is entitled to have copies of the entire medical records of his daughter which should be furnished in full.

Refusal is deficiency of service
There are several decisions by the High Courts and Consumer Dispute Redressal Commissions establishing the right of patient to information and duty of the Hospitals to provide the same. In Kanaiyalal Ramanlal Trivedi v Dr. Satyanarayan Vishwakarma [1996; 3 CPR 24 (Guj); I (1997) CPJ 332 (Guj); 1998 CCJ 690 (Guj)] the hospital and doctor were held guilty of deficiency in service as case records were not produced before the court to refute the allegation of a lack of standard care and thus were made to pay damages to the patient-consumer.

If hospital takes up a plea that record was destroyed, it was held that it could be a case of negligence. In S A Quereshi v Padode memorial Hospital and Research Centre [II 2000. CPJ 463 (Bhopal)] it was held that the plea of destroying the case sheet as per the general practice of the hospitals appeared to the court as an attempt to suppress certain facts that are likely to be revealed from the case sheet. The opposite party was found negligent as he should have retained the case records until the disposal of the complaint. This means that hospital has to pay compensation.

Explaining the consequences of denial of medical record, it was held that an adverse inference could be drawn from that. In case of Dr. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya [2002; 1 CPR 320, I (2006) CPJ 16 (NC)] The National Commission said that not producing medical records to the patient prevents the complainant from seeking an expert opinion and 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.

National Commission in case of Meenakshi Mission Hospital and Research Centre v. Samuraj and Anr [I (2005) CPJ (NC)] held that the hospital was guilty of negligence on the ground that the name of the anesthetist was not mentioned in the operation notes though anesthesia was administered by two anesthetists. There were two progress cards about the same patient on two separate papers that were produced in court.

In Dr. Tokugha Yeptomi V Appollo Hospital Enterprises Ltd and Anr, [III 1998 CPJ 132 (SC)] it was held that not maintaining confidentiality of patient information could be an issue of medical negligence. In this case the HIV status of a patient was made known to others without the consent of the patient. These decisions establish the right of the patient and obligation of hospitals or medical institutions to give medical records.

Bombay High Court
In Raghunath G Raheja v Maharashtra Medical Council, [11.1.1996, AIR 1996 Bom 198, Bench: M Shah, A Savant, https://indiankanoon.org/doc/1068495/] Bombay High Court upheld the right of patient to medical record very emphatically.

We have no doubt in our mind that a medical practitioner should merit the confidence of the patients entrusted to his care rendering to each a full measure of service and devotion. …We are of the view that when a patient or his near relative demands from the Hospital or the doctor the copies of the case papers, it is necessary for the Hospital authorities and the doctors concerned to furnish copies of such case papers to the patient or his near relative.

In our view, it would be necessary for the Medical Council to ensure that necessary directions are given to all the Hospitals and the doctors calling upon then to furnish the copies of the case papers and all the relevant documents pertaining to the patient concerned. The hospitals and the doctors may be justified, in demanding necessary charges for supplying the copies of such documents to the patient or the near relative.

The High Court also directed Maharashtra Medical Council to issue necessary circulars in this behalf to all the hospitals and doctors in the State of Maharashtra. HC said:

“We do not think that the hospitals or the doctors can claim any secrecy! or any confidentiality in the matter of copies of the case papers relating to the patient. These must be made available to him on demand, subject to payment of usual charges. If necessary, the Medical Council may issue a press-note in this behalf giving it wide publicity in all the media”.