Obtaining Information About Medical Records or Reports

Patients have the right to obtain authentic information regarding their medical condition or ailment, method of treatment and options for treatment(( Annexure 8, Clinical Establishments Act (Standards for Hospital Level 1A & 1B), 2010)). Patients have to be provided:

• Adequate information so that they can make an educated decision, give consent or withdraw consent for treatment.
• Medical information in a language that the patient understands, communicated to them in a manner that is not overly technical.
• Information regarding costs/additional cost of treatment or diagnosis at the completion of treatment. The patient or his caretaker has the right to receive an itemised receipt.(( Charter of Patient Rights, Ministry of Health and Family Welfare.))
•  Basic details of the doctors and medical staff treating the patient, including the identities,  qualifications and name of the primary treating doctor/consultant.

Doctors are required to maintain the records of patients they treat for 3 years from the date of starting the treatment(( Section 1.3.1, Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002)), in a format prescribed by the Indian Medical Council.(( Appendix 3, Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002))

Asking for Medical Records or Reports

Patients and their caregivers also have the right to ask for medical records and reports(( Nisha Priya Bhatia v. Institute of Human Behavior & Allied Sciences 2014 SCC OnLine CIC 5092)) of their case, which should be provided to them within 3 days.(( Section 1.3.2, Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002))

Hospital authorities have a duty to provide such information under the law.(( Right to Information Act, 2005; Consumer Protection Act, 1986 (now repealed by Consumer Protection Act, 2019); The India Medical Council Act, 1965; World Medical Ethics, World Medical Association )).Not maintaining such records or not complying with the patient’s request for records in the stipulated time will amount to professional misconduct.(( Section 7.2, Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002)). Further, the doctor shall be liable to disciplinary action.

The following documents can be obtained by the patient from the hospital(( Charter of Patient Rights, Ministry of Health and Family Welfare)):

• Originals and copies of case papers.
• Indoor patient record. For instance, this includes a repository of medical information and history of a patient.
• Investigation reports. For instance, this includes details of the methods including  tests and scans done to help with the diagnosis or management of a disease.
• Discharge summary. This is a document prepared by the attending physician detailing the diagnosis, course of treatment and follow-up (if any) of a patient when he is  discharged from the doctor’s care.
• Death summary, which is given to the caregiver in case of death of the patient.

Filing an RTI Application (Right to Information)

To obtain some of the information given above, you can file an RTI application to both government and private hospitals. Some examples of when you can file an RTI are:

• To claim related documents
• To get COVID-19(( Mr.Venkatesh Nayak vs. CPIO & CMO(EMR), Ministry of Health & Family Welfare and Ors. CIC/MOHFW/C/2020/668909-BJ)) related information such as treatment facilities.
• To access medical records of patients.(( Shri Prabhat Kumar v. Directorate of Health Services GNCTD 2015 SCC OnLine CIC 2742))

If you require any assistance on filing an RTI application to ask for medical records or information, then you can check out the Right to Information topic for further clarification.