Dr. D. K. Patgiri*
Professor of Paediatrics and Vice-Principal
Assam Medical College, Dibrugarh *
|Everyday when we open the newspaper we get news about medical negligence, death due to wrong treatment, Superintendent, Principal gherao, baby lifted from maternity ward and so on. Probably this sort of news items increased after the medical profession was brought under the per view of the. "Consumer Protection Act" in 1992. The number of complaints, allegation and litigations has registered a sharp rise. The medical practice in present times has undergone a sea change, a dramatic mutation. Expectations of the community from medical science and doctors have risen sharply in this age of sophisticated and high-tech man, machine and medicine. Adverse outcome of medical treatment even if it is genuine and unintentional is now often attributed to sub-optimal or deficient treatment amounting to negligence. The global feeling of this trend that people are becoming more demanding, aggressive and even more litigious, spurred by the wave of Consumerism. Understanding the changed scenario doctors need to develop the art of protecting and the understanding of the laws relevant to medical profession. An attempt has been made to present some of the potential sources of medico-legal problems and to prevent and deal with these. All the medical professionals at this hour of confusion and mistrust, need to adopt prophylactic measures. Some of the more common issues to day are as follows:
It is a fact that in India we accord a very low priority to keeping records of patients in all setups. The importance of keeping good patient records in all stations i.e. OPD, Casual Indoor wards, Operation Theatre, Medical record department and also at the time discharge of a patient, cannot be over emphasized. A large number of medico-legal problems are avoidable due to good record keeping. Today things are more complex and patient records need to document historical information viz. the current and previous medical problems, clinical findings, drug allergy, diagnostic tests such as Pathology, Radiology Sonography, Scans etc. In addition there are Specialist consultations, treatment, operation procedures, progress reports, final diagnosis, discharge summary and follow up notes. It also stressed that good records are the best defense against allegations of negligence, medical malpractice.
The medical record, which is correct, clear, comprehensive, chronological a contemporaneous or in other words simultaneous, synchronous and concurrent is termed good medical record. The other reasons for maintaining good records are for medical education and research, audit-medical, economic aspects including cost containment, medical statistics and for legal evidence, which can assist in Judicial proceedings criminal or civil.
Recording Time of Examination: It has been revealed from the retrospective review of hundreds of case records that the time, date of examination and also the particulars of patient in every page are not properly written in the case summary sheets. Proper recording of the time, date, etc of the patients is vital to avoid contentious issues when things go wrong. It is also helpful to avoid delay in giving the treatment if the time of instructions and the implementations are recorded in time.
Preserve all reports:
It is extremely important to keep all the reports of the patient routinely so that have access to them whenever the need arises. The value of this is only realized when have to face allegations of malpractice and start preparing the defense and we discover that all reports are with the patient and we have to rely on our memory or guess work.
Value of Discharge Slip:
It has been observed that the junior most doctors are entrusted to write the discharge slips of the patient at the time of discharge from the hospitals. It has also been found the majority of discharge cards are written rather casually, inadequately and in poor writings. Discharge cards are valuable documents, which contain the advices as regards medicines, diet, further follow up, final diagnosis etc.
Therefore the senior doctors, consultants should check the cards, sign it and give proper advice. It is equally important to keep a record of the discharge cards along with the case summary in hospital for future reference.
Legible handwriting is another important aspect of recording all papers related treatment more so in case of writing a prescription. Doctors are held responsible and liable for negligence for damages occurring on account of illegible handwriting.
Abbreviations: It has been observed in recent year that so many confusing and unacceptable abbreviations are used in medical records. For example:
||Discharged against Medical advice
||Left against medical advice
||As per history sheets
||Plenty of oral fluids
||Something coming out of rectum etc.
It is wise to use only approved, unambiguous, standard abbreviations. These cause confusion and wrong interpretation.
The prescriptions should be written in a proper manner. It should be correct, legibly dated and signed. The advice should be clear-cut regarding the quantity of medicines, and frequency, after or before food and how many days the medicines are to be continued. Moreover patients are asked to report any drug reactions, allergy etc following use of the medicines immediately.
Alteration of records:
As far as possible medical records in summary sheets should not be erased overwritten or inked out. Should your records be under scrutiny at a later date, this could misinterpreted as tampering or altering his record. The opposing Advocates love alternative so that they can introduce an element of doubt in the mind of the judicial authorities.
Referral and receipt for documents handed over:
During referral or transfer of a patient to another hospital for whatever reason detailed transfer note should be given. This could prove invaluable, should any problems are in future.
At the time of discharge of a patient and handing over the reports of all investigation a receipt should be obtained from the patients or parents. A receipt in your possession is only authentic way of disproving the claim of the patient.
- Consent must be taken from the parents of minors, aged below 18
years in India prior performing any surgery or investigation procedure.
Only when a minor presents him or herself for treatment he/she may be
examined without consent.
- Consent should be obtained in patient's own language if possible.
- Informed consent:
This practice of informed consent is not fully utilized by many
hospitals and practitioners. This lacuna is often at the bottom of many
medico-legal problems. The informed consent means:
- Make sure the patient and/or Guardian understands the nature of the patient's medical condition.
- Understands the nature of the proposed treatment procedure.
- Understands the possible alternative treatment or procedures.
- Understands the medically significant risks of the proposed and alternative treatment.
- Denial of consent:
It is equally important to record denial of consent. If you do not do so
many patient/parents may be treacherous at times and are known to deny
that they ever refused o give consent for a particular investigation or
It is the implicit duty of medical professional to treat the patient who is critically ill and during emergency situation to save the life or a person without the formal procedure. Hospital cannot turn away emergency patients without giving proper treatment and advice.
One should be extremely careful in issuing certificates, whether the patient be leave, fitness or death certificates. Many a doctor has landed in difficulty because of trying to oblige a patient by giving a certificate carelessly and casually. In case of problems the doctor will have enough time to repent at leisure for having given the certificate.
Doctor should not divulge any thing that he comes to know in his professional capacity to anyone other than patient/Guardian without their express consent. This is moral obligation as well as a legal obligation, violation of which can cause liability to future damages.
In view of the changed scenario of the present day trader and consumer-like situation, doctors need to develop coping mechanisms. At this critical situation, it is an urgent necessity to have a better understanding of the laws relevant to medical practice and an appreciation of potential problem areas and the knowledge to prevent and deal with them.
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