Section 30 in U.P. Clinical Establishments (Registration and Regulation) Rules, 2016
30. Maintenance of Medical Records.
(1)Every physician shall maintain the medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and appended to these rules as Appendix-E(2)If any request is made for medical records either by the patients/authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours. In case, records are not supplied, it shall be punishable and make out a case for rejection of registration of such Hospital, Medical practitioner or Nursing Home by the competent authority.(3)A registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he/she shall always enter the identification marks of the patient and keep a copy of the certificate. He/she shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared in Appendix-2.(4)Effort shall be made to computerize medical records for quick retrieval."(5)A supervising officer shall be designated who will ensure that conditions mentioned hereinabove are complied with by Medical Practitioners, Hospitals and Nursing Homes whether they are private or the Government. The Government Hospitals including SGPGI or other post graduate institutions shall also comply with the above conditions and provide a copy of entire medical records to the patients or their nominee within the aforesaid period of 72 hours after discharge from the respective hospitals.(6)All Hospitals shall also maintain their record of each and every patient on the website starting from registration of the patient to the date of discharge.
