Patient given first aid / treatment but not hospitalized – No need to maintain medical records

Shri Mahesh Prasad Aggarwal v/s M/s. Kamayani Patients Care India Ltd

The National Consumer Commission held that a doctor / hospital treating a patient or giving first aid does not have to maintain medical records of that patient if the patient is not hospitalized. 

The Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002 lays down that “Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment”.

Thus Hospitals or nursing homes are bound to prepare, preserve and provide medical records of only those patients who are hospitalized and none else.

In Shri Mahesh Prasad Aggarwal v/s M/s. Kamayani Patients Care India Ltd., the patient was on his way to Agra when his vehicle overturned. He was rushed to a nearby hospital where he was examined by doctors, CT scan and x-ray were done, and his hand was plastered. In the meantime the patient’s father and younger brother, a doctor having his own nursing home in Agra, arrived and the patient was taken away to his home. The family then decided to shift the patient to Delhi, but he died in the ambulance in transit.Patient’s family alleged negligence in treating and also in failure to give proper documents at discharge.

Hospital stated that the statutory provisions regarding maintaining medical records or giving documents at discharge were applicable only for indoor patients. In this case the patient was merely given first aid. It was further pointed that the patient was advised hospitalization but his family took him away.

National Consumer Commission held that the patient was never admitted in the hospital and hence the relevant regulations did not apply. The Commission held that there was nothing wrong if the hospital did not maintain record of the patient who was given first aid but never hospitalized.