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Be it a real estate company or a healthcare business; several transactions are documented every single day. Many of these documented transactions are required to be retained for certain periods to meet regulatory requirements.

One such requirement is for healthcare professionals to retain their patient’s medical records, which is referred to as Medical Records Management. This will include almost all kinds of documents relating to your patient’s history, such as clinical findings, tests, notes, etc.

This is done primarily for two reasons:

So professionals can scientifically analyze the profile of their patients and accordingly plan the treatment.
And to reduce medical negligence cases and use such records as evidence in negligence cases.

Medical professionals are more often than not involved in extremely pressurizing and bleak situations where they have to provide their services to patients.

Even though trained to work under extreme circumstances, they can commit a mistake while dealing with loads of paperwork which only multiplies when the patient is admitted on medical insurance.

And since the entire case is dependent upon the documentary evidence in medical negligence cases, maintaining medical records appropriately becomes an even more important task for these professionals.

Moreover, record-keeping also plays a huge role in the approval of medical claims raised by patients for treatments, where it becomes the sole responsibility of the doctor or the hospital to provide copies of the documents as needed.

Resultantly, poor record management can:

Put healthcare professionals in legal trouble.
Decline your customer’s insurance claims.
And even suspend your practice license.

The process of medical record management can include other healthcare professionals apart from the doctor, like the paramedical staff and nurses too. This means in cases of negligence; even they can be held liable.

So how can one do it efficiently? We have a solution for you. But first, let’s go ahead and learn about some challenges healthcare professionals face on a daily basis.

Challenges Faced by Healthcare Professionals with Traditional Methods of Record Keeping

The manual paper-pen method is the most commonly used method of record-keeping across the country. Such a system of records management comes with certain restrictions and shortcomings, which later pose high risks to those working in the industry.

1. Storage

Like any other industry, the healthcare sector also struggles with managing tons and tons of medical records every day. With an increasing number of patients admitted to hospitals every day, the stacks of paper documents are also increasing significantly. Thus, storing them in maintainable situations is becoming a task for hospitals.

2. Retrievability

The stacks of paper can be stored in a room but imagine being in a position where you have to retrieve a particular patient’s history from such a huge stack. Would you not be worried about it at all? Well, anyone would, and many are too. The retrievability of medical records is another primary concern of these professionals since it poses unavoidable financial and legal risks to them.

3. Confidentiality

Maintaining the confidentiality of patients is the sole responsibility of the hospital or the doctor. Any healthcare professional can be held liable if they jeopardize the confidentiality of the patient’s documents.

Following are a few situations where giving out a patient’s personal information is legal:

When a patient is referred to a different doctor or a hospital.
When the court or similar authorities have requested the same.
Where the insurance companies require the information to provide a claim.

Any time a patient’s documents fall into unauthorized hands, they can resultantly sue the professional or the hospital for such negligence, which becomes very easy when you follow the pen-paper record-keeping system.

The Increasing Need to Digitize the Process of Medical Record Management

Fine, there are a few challenges, but is digitization the only answer?

From what we’ve learned about the industry, medical record keeping is a very important part of any patient’s treatment, and it’s a testament to the fact that the patient’s treatment was carried out in the best possible manner by taking all necessary precautions.

These records are used as documentary evidence as prescribed by section 3(2) of the Indian Evidence Act 1872:

(2) [all documents including electronic records produced for the inspection of the Court;] such documents are called documentary evidence.

Moreover, since the number of people relying on medical insurance to pay for their hospital bills has increased, the liability of hospital staff and healthcare professionals to manage the records appropriately has also increased. This is because negligent management of these records can decline the patient’s claim.

Negligence cases filed by patients can question the professionals on various parts such as the following:

The patient can deny giving consent to the procedures that were carried on; in such scenarios, if a professional can present to the court a properly acknowledged consent form, they can prove that all procedures were conducted with due consent and avoid the repercussions.
The patient can also question the procedure followed and allegedly point towards a surgeon’s negligence as a result of operative complications. In such cases, an operative note can come to the professional’s rescue and prove that all necessary measures were taken to avoid such complications.
In cases where a doctor refers a patient in severe circumstances, and the patient thereafter chooses not to go to the referred professional, the doctor again, with the help of a referral note, save himself from any repercussions.
Where the doctor failed to mention a date on the prescription, he can also be held liable when the patient leverages the same to buy the previously prescribed medications again.

And many similar circumstances.

A doctor is a prime figure who has to ensure that all documents related to the patient’s treatment, discharge summaries, physical examinations, and operative records are maintained to save himself from such scenarios. However, this does not deter other professionals, such as paramedics and nurses, from legal penalties. This is because medical record management is a cumulative effort and responsibility of almost all healthcare professionals involved in treating a patient.

Proper management of these records is also essential because of the limitation of the manual method of record keeping. Certain documents, such as discharge notes and summaries, become extremely important for the court to realize whether the treatment was done properly or impatiently and whether there were any discrepancies on the part of either of the parties.

What are Some Regulations and Legal Provisions related to Medical records Management?

The Regulation of the Medical Council of India

The MCI is a statutory body that supervises the medical professional practice in the country and ensures the standards of quality service are maintained across states. In order to deal with the increased cases of medical negligence, the MCI laid down a few medical records management governing provisions which are as follows: (Referred from Medical Council Of India’s 2002 guidelines)

Section 1.3.1 of Appendix 3 mandates the system of indoor records management in a standardized proforma for a period of 3 years after the treatment of a patient begins.
Section 1.3.2 states that whenever a request is made by the patient himself or by any authorized attendant or body, the same shall be processed within 72 hours from the acknowledgment of such application.
Section 1.3.4 states that it is mandatory for hospitals and individual practitioners to maintain a record of all the certificates thus issued concerning the treatment with at least a single mark of identification.
And most importantly, Section 1.3.4 addresses the need for an electronic management system and states that all hospitals and individual practitioners must make efforts to computerize/digitize the records management system to improve the retrievability process.

Provisions regarding the Retention Period of medical records:

Following as a few provisions/ guidelines of different statutes/ statutory bodies regarding the retention period of medical records:

The Limitation Act 1963 and the Consumer Protection Act 1986 bar a patient from filing a case of negligence after 3 years. Thus, hospitals must maintain an archive of these records for 2 years in outpatient cases and 3 years in inpatient cases.
Even the Medical Council of Indian directs the hospital to maintain such records for a period of 3 years.
The Income Tax Rules, 1962 mandates that individual practitioners must keep a daily record of cases as required by the Form 3C for a minimum of 6 years.
Similarly, the Punjab Medical Manual mandates that medicolegal records must be maintained with the hospital professional for a minimum of 12 years.
The Directorate General of Health Service vide letter No. 10-3/68-MH states:
1. The inpatient medical records must be maintained for ten years.
2. Medicolegal records must be maintained for 10 years.
3. And the outpatient records for 5 years.
The provisions of the Pre-Conception Prenatal Diagnostic Test Act mandate the retention of records for 2 years.

In cases where a professional fails to comply with the regulations and guidelines as mentioned above and denies because of any reason to present the record within 72 hours of the application of an authorized person, the professional is said to have performed professional misconduct for which the Medical Council of India can cease the license of such a professional in extreme cases.

In the case of Kanaiyalal Ramanlal Trivedi v Dr. Satyanarayan VishwakarmaI (1997) CPJ 332 (Guj), the Hon’ble High Court of Gujrat gave the verdict that since the hospital and the doctor could not defend themselves in the lack of standards case by presenting proper case records, they were guilty of deficiency in service.

Similarly, the Hon’ble seat of NCDRC held in the case of Dr. Shyam Kumar v Rameshbhai, Harmanbhai Kachiya 2002;1 CPR 320, that not providing the patient required records of treatments keeps him from seeking further opinion from experts, and it is the duty on the part of the hospital and the doctor to provide for the same; failing which can force courts to draw adverse inferences.

The Guidelines of the Electronic Health Record Standards for India (2016)

For a hospital or individual practitioner to put in place an electronic system of record keeping, the following guidelines are laid down:

For Hardware Solutions:

The system should have appropriate storage capacity, and a method of backing up stored information should be put in place.
Everything should be planned prior in case of system failure and redundancies to meet the needs of data and document management.
The system should be capable enough to store medical records securely.
The hardware must be assessed in a periodical manner to prevent the system’s complete failure from time to time.
The system should meet the quality and capacity requirements and undergo upgrades from time to time to ensure efficiency.

For Software Solutions:

Any software used by hospitals or healthcare professionals to record, store, create, manage or retrieve medical records must maintain a high standard of security and ensure authentication.
Audit trail functionality should be there to support the privacy and security policies of the patients.
Have advanced search capabilities to ensure smooth functioning and facilitate the process of information retrieval.
And must have other functionalities as may be required for the efficient working of the system.

Document Management software for Medical - dox2U

Need for a Document Management System for medical records:

Managing medical records in a hardware system will not help you since hardware can give up on you anytime. A system failure can take you down on a busy day; all it takes is a single mistake with a patient. You will be required to present your case in court, and no lawyer can provide you with a defense without available records.

This is why opting for cloud-based software is a more feasible option to help you dodge certain situations like these.

But the question is: where will you find a cloud-based document management system that will help you deal with all these and at the same time match the standards as required by Electronic Health Record Standards for India (2016)?

You’re lucky because we have exactly what you’re looking for.

dox2U: a cloud-based document management system

dox2U is a comprehensive and highly-configurable solution for your problem. It can help you manage everything related to paper-based documents. You can quickly scan, upload, retrieve and organize your daily records and retrieve them whenever required within seconds.

Core Functionalities of dox2U:

1. Document Management

Managing day-to-day documentation becomes a never-ending process and also very hectic. dox2U, with the help of its intelligent capabilities, lets you easily upload, tag, edit and even organize these documents for as long as required. Thus, you will be empowered with the features you need to comply with the regulations.

2. Secured Guest Access

Security is one of the biggest challenges, and dox2U solves it instantly with its guest access feature. Traditionally one would need to print a paper to get approvals from different authorities. With dox2U, you can quickly share your document with people within and outside your organization and revoke access whenever required to stay on the safer side.

3. Advanced Search

As required by the Electronic Health Record Standards for India (2016), dox2U also comes with advanced search functionalities that significantly ease the process of retrievals. With dox2U’s text and filter-based search, one can quickly retrieve the record even if one can’t remember the title given to the file. Sounds impressive, right?

4. Shared Workspace

A shared workspace to maintain transparency and eliminate delays in information retrieval. With this functionality, you can collaborate with other professionals you work with and stay on the same page as them.

5. Audit Logs

Another must-have capability, as required by Electronic Health Record Standards for India (2016), that dox2U has is Audit Logs or Trails. With this functionality, one can quickly get notified of the activities performed on shared docs. This holds people accountable for their actions, and you can prevent yourself from legal troubles easily.

To conclude, we would like to point out that having a system to manage medical records is essential. You would need robust software to help you work stress-free and bring efficiency back to you.

Why Should you Give dox2U a Try?

Because it comes with pay-as-you-go plans, does not require upfront investments, can check dox2U’s price page.