WBCE Rules 24Chapter III · Responsibilities, Obligation and Rights

Section 24 · Access to Medical Records

(1)

As soon as possible, after the purpose for which the patient had visited or had been admitted or the episode of care is finally over, or the patient is discharged or transferred or referred, the clinical establishment shall provide the patient with a brief, written summary of medical record related to observation, treatment, test, investigation, advice diagnostic opinion and clinical outcome pertaining to the patient care free of cost:Provided that, the patient is entitled to get such Summary Medical Report even if she was discharged against medical Advice.Explanation1. An episode of care consists of all clinically related services for one patient for a discrete diagnostic condition from the onset of symptoms until the treatment is complete. Thus, for every new problem or set of problems that a person visits her healthcare provider, it is considered a new episode. Within that episode the patient will have one or many encounters with her clinical care providers till the treatment for that episode is complete. Even before the resolution of an episode, the person may face a new episode that may be considered as a distinctly separate event altogether. Thus, there may be none, one or several ongoing active episodes. All resolved episodes are considered inactive. Hence they become part of the patient's past history. A notable point here is that all chronic diseases are considered active and may never get resolved during the life-time of the person, e.g., diabetes mellitus, hypertension, etc.Explanation 2. A clinical outcome is the change in the health of an individual, group of people or population which is attributable to an intervention or series of interventions.

(2)

Such Summary Medical Report under sub-rule (1) shall be provided by the Primary Consultant containing such particulars which includes but not limited to -

(a)

the reasons for admission/attendance/visit, significant clinical findings, provisional diagnosis and results of investigations, particulars of treatment administered or procedure done and the nature of the health service rendered; and

(b the principal diagnosis and condition of the patient; and

(c)

follow-up advice, medication and other instructions and when and how to obtain urgent care when needed in an easily understandable manner; and

(d)

any other particulars which shall be useful for future health care of the patient.

Explanation. 'Principal Diagnosis' means the main medical condition that is ultimately determined to have caused a patient's admission to the hospital. The principal diagnosis is used to assign every patient to a diagnosis related group. This diagnosis may differ from the admitting and major diagnoses.

(3)

In case of death, such Summary Medical Report shall be accompanied with a copy of Medical Certification of Cause of Death under the Birth and Death Registration Act, 1969 [Act No. 18 of 1969] as amended from time to time.

(4)

Notwithstanding any other pending financial obligation, the patient or patient party is entitled to reproduction/get, at one's expense, the relevant part or parts of the medical record and reports pertaining to his/her healthcare, on demand in addition to the Summary Medical Report under sub-rule (1).

(5)

On such demand during the course of treatment or after the discharge, transfer or death, the clinical establishment, within a reasonable period not exceeding one working day, shall make available such hard copy to the patient or patient party either at free of cost or after receiving payment of such charges at a reasonable rate not exceeding the rate of Rs.5 per A4 size pg or Rs.50 per Compact Disc or any such rate as may be notified:Provided that, the clinical establishment may refuse to deliver such records after the retention period of such records as specified in schedule VI is over.

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