WBCE Rules 18Chapter II · Chapter II

Section 18 · Mandatory record keeping

(1)

The clinical establishment shall exercise reasonable care and take all necessary measures including generation and maintenance of such standards of registers and records in such a manner as specified in schedule VI in order to ensure proper patient care, and legal formalities including medico-legal formalities. The clinical establishments shall also abide by the conditions laid down in section 7 of sub-section 3 (n) of the Act.

(2)

The clinical establishment shall ensure that -

(a)

all the Registered Medical Practitioners of the clinical establishment are following the guideline of Medical record keeping issued by the Medical Council of India or West Bengal Medical Council or such guidelines as may be notified from time to time;

(b)

the records, registers and documents generated and maintained by it is being entered fully, chronologically and legibly and is not being tampered with; and

(c)

the records, registers and documents are being updated and duly authenticated by an accountable person periodically at least at monthly interval.

(3)

Unless mentioned otherwise, the clinical establishment shall generate and maintain all the mandatory registers and records mentioned under the Act or rules in hard copy having machined-pressed page number and duly authenticated:Provided that, the Licensing Authority may consider generation and maintenance of such registers and records in electronic form in any technologically appropriate medium if he/she is satisfied with such manner at the time of inspection or enquiry.Explanation 1. Authentication of registers and records may be done by affixing a written signature, or a digital signature with identifiable initials or computer key along with date and time.Explanation 2. "electronic form' means such term as may be defined under section 2(1) (r) of the Information Technology Act, 2000 [Act 21 of 2000].

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