Doctors need to maintain patient record for 3 years: NMC Draft

New Delhi: All the doctors will have to maintain the medical records of patients for three years from the last date of treatment, the National Medical Commission (NMC) has stated in the recently published Draft Registered Medical Practitioners (Professional Conduct) Regulations, 2022.

Mentioning it to be one of the prime responsibilities of the Registered Medical practitioners, the Ethics and Medical Registration Board (EMRB) of NMC has also listed down the other duties of the doctors. Such duties include making the medical records available on request, digitization of the records, providing honest certificates, reports and other documents etc.

Any violation of these rules may cost the medical practitioners a suspension of practice for a period ranging from one month to a maximum period of three months.

The Draft in its Guideline 8 has also included a format for maintaining medical record of the patients. As per the format given by NMC, the doctors should ensure keeping the details including the name of the patient, age, sex, address, occupation, Date of last visit, Clinical note (summary) of the case, Prov, Diagnosis, Investigations advised with reports, Advice, Follow up, Date Observations, Signature in full and finally the Name of Treating Physician.

Medical Dialogues had recently reported that in an attempt to address the various issues of professional conduct of registered medical practitioners, the Ethics & Medical Registration Board (EMRB) of NMC has introduced the Draft RMP (Professional Conduct) Regulations, 2022. These new regulations have addressed the issue of Professional Conduct of Registered Medical Practitioners (RMPs) including their duties and responsibilities, continuing professional development program, remuneration, prescribing generic medicine, prohibition of commission, restriction on advertisement, responsibilities regarding sale of drugs, medical reports, etc.

Also Read: Drinking on duty can get doctors suspended for 3 years: NMC draft RMP ethics Guidelines

The Professional Conduct of the registered medical practitioners have specified in the Chapter 2 of the Draft Regulations. Listing down the Responsibility of the RMPs regarding the Medical Records, the Section 13 of the Draft read as follows:

Responsibility of RMP regarding the Medical Records:

“A. Every self-employed RMP shall maintain medical records of patients (outpatients or
inpatients) for 3 years from the date of the last contact with the patient for treatment, in a
standard proforma laid down by the NMC. (Guideline) (L2)
B. If any request is made for medical records to a RMP responsible for patient records in a
hospital or healthcare institution either by the patients / authorized attendant or legal
authorities involved, the same may be duly acknowledged and documents shall be
supplied within 5 working days. (L2)
C. In case of medical emergencies, the medical records should be made available on the
same day. (L2)
D. Efforts shall be made to computerize patient’s medical records for quick retrieval and security. Within 3 years from the date of publication of these regulations, the RMP shall
fully digitize records, abiding by the provisions of the IT Act, Data protection and privacy
laws, or any other applicable laws, rules, and regulations notified from time to time for
protecting the privacy of patient data. (L1, L2)
E. RMPs are in certain cases bound by law to give or may from time to time be called upon
to give certificates, notifications, reports, and other documents of similar character, signed
by them in their professional capacity for subsequent use in the courts or administrative or
other purposes. Such reports, certificates, or documents should not be untrue, misleading,
or improper. A self-employed RMP shall maintain a Register giving full details of such
certificates issued by him/her. (L3).”
While the violation of the rule regarding maintaining medical records for three years has been declared to be a Level 2 (L2) violation, Level 3 (L3) penalty has been specified for the rules of issuing certificates, notifications, reports and other documents.
Guideline 4 of the Regulations mentions that when the State Medical Council or EMRB or NMC investigates a case, the disciplinary action will be awarded while keeping in mind the severity of the act of commission of omission.

These Regulations have graded the disciplinary actions at five levels. As per the Regulations Level 2 penalty may be awarded even when the role of the doctor in causing direct harm
was not conclusively proved but the doctor was found to have breached any of the codes listed
above.

In this case, “The maximum action is a suspension of the license to practice for up to one month
(30days).”

Level 3 penalty may be awarded when the role of the doctor in causing direct harm was
conclusively proved and the doctor was found to have breached relevant regulation.

“This maximum action is a suspension of the license to practice for a maximum period of three
months. Holding suspension can be given in this level as per regulations,” read the guidelines.

Also Read: NMC ethics regulations 2022: Doctors write to NMC Ethics Board, ask to extend Deadline for submitting comments

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