CONTENTS
- 1. Collection of Medical Records | Concept and Importance
- - Securing Evidence and Managing Legal Liability
- - Main Types of Medical Records
- 2. Collection of Medical Records | Management and Preservation
- - Importance of Records Management in Preparing for Civil and Criminal Disputes
- - Timing of Records Disposal and Legal Risk
- 3. Collection of Medical Records | Responding to Requests for Medical Records
- - Requests by Patients and Third Parties to Inspect and Copy Records
- - Legitimate Requests, Grounds for Refusal, and Legal Liability
- - Internal Response Process of a Medical Institution and the Role of Personnel
- 4. Collection of Medical Records | Records Management for Responding to Medical Disputes
- - Internal Examination of Evidence and Cooperation with Appraisal Procedures
- 5. Collection of Medical Records | Dispute Prevention and Defense Strategy
- - Records Management System
- - Establishing a Defense Strategy
- 6. Collection of Medical Records | Legal Support
1. Collection of Medical Records | Concept and Importance
The collection of medical materials is a key means by which a medical institution and a medical professional prove the lawfulness of the medical procedures performed in the course of treatment.
All medical materials, such as medical records, test results, and imaging materials, play an important role in assessing the legal responsibility of a medical professional and in protecting the credibility of a medical institution in any medical dispute that may arise in the future.
Systematic management of materials and their prompt securing enable a medical institution to respond reasonably in a dispute situation.
Securing Evidence and Managing Legal Liability
When a medical dispute arises, medical materials serve as the basis for clarifying the facts of the dispute and determining the scope of the legal liability of the medical institution and the medical practitioner.
If securing materials is delayed or omitted, the medical institution may receive an unfavorable legal determination, and uncertainty increases in determining whether there was negligence.
Therefore, the medical institution should establish internal processes that allow it to systematically manage the necessary medical materials from the early stage when a dispute arises and to provide them appropriately in accordance with legal procedures.
Main Types of Medical Records
The main medical materials that a medical institution must manage are as follows.
ㆍ Medical Records
The basic document recording the patient's condition, diagnosis, and course of treatment
ㆍ Surgical Records
A record of the surgical procedure, the course of performance, and the physician's judgments related to the surgery
ㆍ Test Results
Objective test results such as blood tests and biopsies
ㆍ Physician's Opinion
The medical professional's diagnosis and treatment opinion, and the basis for judgments during the course of treatment
ㆍ Imaging Materials (CT, MRI, X-ray, etc.)
The basis for confirming the condition and establishing a treatment plan
These materials serve as key evidence that establishes that the medical institution and the medical professional performed the medical practice appropriately and that strengthens the legal defense in a medical dispute.
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2. Collection of Medical Records | Management and Preservation
Under the Medical Service Act and Article 15 of its Enforcement Rules, medical institutions have a duty to retain medical data, such as medical records, for the statutory period.
The retention period differs by type of material, and it serves as an essential standard for responding to disputes and managing legal liability.
The main retention standards are as follows.
ㆍ Medical records: 10 years
ㆍ Prescriptions: 2 years
ㆍ Surgical records: 10 years
ㆍ Records of test content and test findings: 5 years
ㆍ Radiographic images (including imaging) and findings reports: 5 years
ㆍ Nursing records and midwifery records: 5 years
ㆍ Duplicates of medical certificates, death certificates, postmortem examination reports, and the like: 3 years
In addition, a medical institution may retain medical records in their original form on electronic media, such as microfilm and optical disks, in which case the person responsible for the filming must record the date and time of filming and his or her name on the cover and sign or seal it.
Importance of Records Management in Preparing for Civil and Criminal Disputes
Imaging materials such as CT and MRI scans and medical records are key materials used as objective evidence in medical disputes.
Considering the possibility of civil and criminal litigation, it is crucial for a medical institution to manage all medical materials systematically and to have an internal management system that can provide them promptly when necessary.
Where material management is inadequate, the medical institution may receive an unfavorable legal judgment during the dispute, and limitations may also arise in the medical professional's exercise of the right of defense.
Timing of Records Disposal and Legal Risk
Medical materials whose statutory retention period has passed may be discarded, but discarding materials with the potential for a dispute too early may give rise to legal liability.
In particular, materials with an early disposal point, such as CT and MRI imaging data, cannot be used as evidence unless they are secured and preserved before a dispute arises.
Therefore, a medical institution should operate a data retention policy that both complies with retention periods and prepares for disputes, and it should minimize legal risk by clearly managing the timing and procedures for disposal.
3. Collection of Medical Records | Responding to Requests for Medical Records
Under Article 21 of the Medical Service Act, when a patient requests to view or to receive copies of all or part of their own medical records, a medical institution cannot refuse without justifiable grounds.
In this case, the requested materials include both additionally entered or amended records and the original records, and the medical institution must respond promptly and accurately.
Requests by Patients and Third Parties to Inspect and Copy Records
A request by a third party (family member, agent, public institution, and the like) is permitted only when strict requirements are met.
The main requirements are as follows.
1. Request by a family member
ㆍThe patient's letter of consent and documents proving the relationship must be attached
However, this is limited to cases where the patient and other lineal ascendants or descendants, and the spouse's lineal ascendants, are absent
2. Request by an agent
ㆍThe patient's letter of consent and documents evidencing the power of agency must be attached
3. Where the patient's consent cannot be obtained
ㆍRequired documents, such as a family relationship certificate and a death certificate, must be submitted
4. Request by a public institution
ㆍA legitimate purpose, such as criminal or civil litigation, military court proceedings, industrial accident, automobile insurance, or military service management
When a medical institution receives a request, it must always confirm whether the submitted documents and requirements are satisfied, and where the requirements are not met, it must clearly record the grounds for refusal.
Legitimate Requests, Grounds for Refusal, and Legal Liability
Where a medical institution refuses a request from a patient or a third party without justifiable reason, legal liability may arise.
Conversely, in providing materials, the institution must not violate legal obligations such as the protection of personal information and the maintenance of medical confidentiality.
▶ Legitimate provision:
Providing materials lawfully after satisfying all the requirements set by statute and going through an internal verification procedure
▶ Grounds for refusal:
Failure to satisfy statutory requirements, nonexistence of the materials, expiration of the retention period, and the like
A medical institution should be able to clarify its responsibility when a dispute arises through systematic record management from receipt of the request, to verification, to provision of the materials.
Internal Response Process of a Medical Institution and the Role of Personnel
For efficient and secure provision of materials, a medical institution should operate the following internal processes.
▶ Request intake officer
ㆍConfirming the content of the request, guiding on the necessary documents, and managing intake records
▶ Legal/management officer
ㆍReviewing the lawfulness of the request and confirming legal liability and personal information protection
▶ Material provision officer
ㆍExtracting materials, making copies, and transmitting them
ㆍElectronic documents may be provided under the Digital Signature Act
▶ Post-management
ㆍKeeping records of material provision
ㆍMaintaining supporting materials in the event of a dispute
Such a systematic response plays a key role in securing the legal stability of the medical institution, managing the liability of medical practitioners, and preventing disputes.
4. Collection of Medical Records | Records Management for Responding to Medical Disputes
A medical institution should establish a stage-by-stage system from medical material collection to litigation response.
Through this, prompt and stable response is possible when a dispute arises, and the legal liability of the medical professional can be managed effectively.
▶ Material collection:
Securing relevant medical materials such as medical records, test results, surgical records, and imaging materials quickly and accurately
▶ Material verification:
Confirming the completeness and accuracy of the collected materials and checking whether they are in a state fit for legal submission
▶ Material storage and management:
Systematic storage that complies with the statutory retention period and allows immediate use when a dispute arises
Through this process, a medical institution can respond stably even in a dispute situation.
Internal Examination of Evidence and Cooperation with Appraisal Procedures
A medical institution should systematically analyze the materials and, where necessary, actively cooperate with the appraisal procedure.
▶ Internal examination of evidence:
Verify the facts relating to the medical act, and prepare a list of evidence that can be submitted
▶ Cooperation with the appraisal procedure:
Provide medical records and imaging materials, and support expert explanations to secure an objective basis for the defense
Through this, a medical institution can secure objective evidence based on medical data and, together with that, establish a basis for responding to a dispute, thereby preventing an unfavorable situation.
5. Collection of Medical Records | Dispute Prevention and Defense Strategy
Systematic management and use of materials reduces the risk of medical disputes and, when one arises, strengthens the medical institution's ability to defend itself.
Records Management System
To prevent medical disputes in advance, a medical institution should manage its records thoroughly.
By accurately and thoroughly preparing the records generated in the course of all treatment, surgery, and examination, they can be used as objective grounds in the event of a future dispute.
In addition, the institution should comply with the statutory retention period and should separately keep important materials that may give rise to a dispute so that they can be used immediately when needed.
Through regular internal inspections, the institution can review its record management system and identify potential problems in advance, thereby minimizing the possibility of a dispute arising.
▶ Summary
ㆍ Strengthening of retention policy
ㆍ Regular internal inspections
Establishing a Defense Strategy
A medical institution should have a defense strategy in place that allows it to respond promptly and effectively when a dispute arises.
By securing objective medical data such as medical records, test results, and imaging materials, a medical institution can prove that the medical act was performed appropriately in accordance with legal and medical standards.
When a request arises, the institution should verify the materials in accordance with internal procedures and provide them promptly to minimize legal liability.
In addition, it is important to clearly designate the person in charge at each stage, such as data management, verification, and provision, so that an organized and systematic response is possible.
▶ Summary
ㆍ Building a prompt response system
ㆍ Clarifying the roles of those in charge
6. Collection of Medical Records | Legal Support
The process of collecting medical materials is not limited to mere record management; it is an important step that can strengthen the legal defense of the medical institution and the medical practitioner when a medical dispute arises.
When a dispute arises, responding to legal procedures hastily may lead to misjudging which materials to submit and how to secure their evidentiary value, and this can result in an unfavorable outcome.
Therefore, it is very important to receive the assistance of a specialist attorney with extensive practical experience in medical disputes, to secure legality and objectivity from the material collection stage, and to organize and submit materials in accordance with legal requirements.
This firm provides advice not only on the overall process of responding to medical disputes but also on improving the internal record management system and work processes of medical institutions.
In particular, through a tailored strategy that protects the position of the medical institution and the medical practitioner in areas such as material collection, evidence verification, and legal submission, it supports efficient and stable responses even in dispute situations.
If you have difficulty with managing the collection of medical materials, designing internal processes, or responding to legal procedures, you may request help from a medical specialist attorney at any time.
