Maintain authentic patient records or face action- NMC warns medical colleges

New Delhi: The National Medical Commission (NMC), has issued a public notice directing all medical colleges to maintain authentic patient records, including mandatory registration using the Ayushman Bharat Health Account (ABHA) ID. This move aims to ensure the authenticity and traceability of patient records and clinical data.

As per the latest guidelines, all in-patient records must include the name and signature of the unit faculty and senior residents involved in the patient's care. Additionally, all investigative reports must be signed by faculty from the relevant department.

The NMC has further warned that any college found maintaining fake patient records will face strict action, which could extend to both the institution and the concerned faculty members. To enforce compliance, the Commission may verify the authenticity of records during inspections and assessments.

In its notice, the NMC observed that despite its earlier directive in June 2024, several medical colleges were not consistently following the requirement of linking patient records with ABHA ID. In its earlier notice, the apex medical commission had directed all medical colleges/ institutions under its jurisdiction to ensure mandatory recording of ABHA-ID during patient registration in associated hospitals.

"The intent is to ensure availability of authentic record of patients and the clinical material in the associated hospital of the Medical College. However, it has been noticed that this requirement is not being followed by all Medical Colleges and for all patients," the NMC mentioned and issues directions for the institutes.

In view of the same, all medical colleges/institutions under the administrative domain of the National Medical Commission are advised to take the following steps with immediate effect:

The college shall maintain the records of all patients. All in-patient records should have the entry of the unit faculty and senior residents with their name and signature authenticating that they have admitted and seen the patient.

All investigative reports should be signed by a faculty in the corresponding department. Verification of the authenticity may be conducted by the NMC as part of the assessments.

If at any point of time, the patient records are found to be fake; action shall be taken against the concerned faculty & the college/institute.

The National Medical Commission (NMC) in its 14th meeting held on 01-05-2024 decided that all medical colleges must ensure ABHA lD as pre-requisite for registration of patients visiting for the OPD/IPD/emergency services in hospitals attached to them. All patients, OP/IR must have registration done with the ABHA lD in addition to hospital's registration number.

The Commission endorsed a strong need to have authentication of patients and other clinical material in the hospital for decision on the prospects of a college (increased seats in UG or PG, new college, annual renewal of permission/recognition to admit students). The creation of ABHA lD is very simple process and can be facilitated conveniently with the possession of Aadhaar Card that has already been extended to people on a large scale.

However, no patient should be denied treatment without the ABHA lD. For decisions in the assessment for the academic year of 2A25-26 and thereafter, the patients and related clinical material authenticated with ABHA lD will only be counted, the NMC notice had stated.

To view the official Notice, Click here : https://medicaldialogues.in/pdf_upload/nmc-maintenance-of-authentic-patient-records-by-medical-colleges-296008.pdf