MEDICAL NOTES WRITING ON CASE PAPER - A NEED TO MAKE NOTES WRITING DOCTOR FRIENDLY

The dawn of third millennium has seen many ups and downs in human relations with many turbulent changes in the society. The age old good relations between the patient and the treating physician is being turned into a love and hate relationship. In this era of specialization and super specialisation the focus, of medical profession is progressing from a noble one to commercial one. The increasing cost of investment for medical practice with fierce competition right from the start of medical education is partly responsible for the total commercial approach. The patients are also lured and attracted by the star facilities and overall look and getup of hospital rather than quality care and competency of doctors.

Doctors are expected to chart the course of the health of their patients with minimal health hazards. Any action or inaction of the doctor, that may increase the health risks may result in allegation of breach of duty of doctor. If a health hazard occurs due to breach of duty, the doctor has to face litigation charges.

Maharashtra Medical Council Rules 1969R-69, says that hospitals and doctors cannot claim any secrecy or confidentiality in matter of copies of case papers and relevant documents relating to patient care and management. The copies of case paper should be furnished on demand from patient or relative, on payment of necessary charges. In any litigation or trial, hospital record is the most important evidence. Case paper is a valid document to defend in medical negligence and it is accepted in the court as one of the best evidence of care rather than cure. A good record speaks of all the care given to the patient and sloppy incomplete record suggests negligence and equals liability, regardless of the standard of care practiced. Medical records can be friend as well as foe of a doctor.

Medical record of patients carry confidential information and it has to be released only with proper consent and requisition to the parents, or guardian or care taker after verification of the proof and identity. No one should have easy access to trace case paper.

It should never be left in the bedside of patient. All the medical records should be clean, complete, chronological comprehensive, correct and without manipulation and overwriting.

Most of the medical textbooks give lot of information on case management but medical notes writing on cases paper has not been emphasized in any of the textbook neither it is a part of medical curriculum. In Government medical colleges and District hospitals, medical notes writing has got least priority. Medical record section has more than 60% case papers incomplete and residents are called for completing it every six months on change of rotation of their posting. The commonest language of medical notes writing in practice after senior rounds is history reviewed, patient examined and continue all. In a study done at J. J. Hospital, such types of notes were seen in 94.23% cases out of 1500 case papers which were retrospectively analyzed.

Medical notes writing begins right from the time of admission of patient. The name, address, contact number should be written correctly on the case paper. The patient was brought by whom and his/her address also should be their. Even the OPD paper should have date, time and complete findings and treatment. Whether the patient was admitted on out patient basis or as an emergency also has to be mentioned clearly. History in detail has to be recorded. In our study, the only area where perfection was found was history writing (98.86%). Date and time is a very important record on case paper and name and signature in legible hand writing below the notes of the treating doctor is mandatory (because of illegible prescription instead of asthma medicine patient received diabetes medicine causing hypoglycemia and drained damage, doctor was asked to pay 25% and chemist 75% of awarded amount because of negligence, Pendergast V. Sam & Ltd. (1988) independent 17th March Queens bench division AULDJ) this decision is affirmed on appeal (1989) Times 14th March, CA.). Temperature charts, diet charts, intake output charts, weight record charts, needs to be maintained with daily proper recording. Complete list of investigations with dates should be available at a glance. Informed high risk consent in a correct language in the format of standard consent with signature of the parent and witness has to be there whenever any procedure is done or general condition of the patient is informed including high risk consent. Complete discharge summary, final diagnosis and in case of death immediate cause of death must be mentioned on the case paper. If postmortem was advised, consent for postmortem with signature and witness there off has to be there. If patient refuses postmortem then also it has to be recorded in parents own hand writing with witness.

It is also important to note down details of telephonic consultations from seniors but however, the treatment followed telephonically has to be endorsed by the concerned doctor. Over writing, scratching, scoring should be avoided and in case of such mistake notes should be written freshly with signature. In case of very serious patient, the day to day care and prognosis has to be explained and high risk information has to be given to patients. Changing of Jelco, Ryle's Tube, indwelling catheters, endotracheal tubes, need to be mentioned with date and time. In everyday notes, the most important part is to stress on vital parameters viz. temperature, pulse, heart rate, respiratory rate, blood pressure and overall activity and sensorium of the patient. In addition in case of newborn colour temperature, tone, posture and feeding details should be clearly mentioned. In much litigation gross negligence have been proved as "case paper speak for themselves".

A doctor has to inform the police in following circumstances. Failure to inform police in such cases may result in penal consequences. Police must be informed in (i) cases of suspected homicide, (ii) cases of suicidal deaths, (iii) unknown unconscious patients, (iv) death on operation table (v) suspected unnatural death (vi) sudden, unexpected, violent and unexplained death, (vii) instant death after treatment or reaction of medicine, and a (viii) married lady dying within seven years of marriage due to any reason.

It is advisable to inform police in following circumstances (i) undiagnosed death within 24 hours of a admissions or specially if there is any suspicion (ii) any cases of poisoning (iii) accidental deaths and death within 24 hours of admission, abandoned babies

Information to police shall preferably be in writing and the written acknowledgement should be obtained. If the information is telephonic one must not down name, buckle number and designation of the police.

There has to be frequent checks and counter checks every day while examining the patients during grand rounds. There should be an orientation training programme for all the doctors to make notes writing on case papers "doctor friendly". I.A.P. with its medicolegal aid cell should bring out guidelines for record keeping and maintenance.
References :
  1. Doctors and criminal law, Dr. S.K. Tiwari, Mahesh Baldwa, Indian Pediatrics, Vol. 39, No.12, Dec. 2002, page 1119-1124.
    Pandit M.S., Pandit S. Medico-legal systems module I, Pune, Symbiosis Centre of Health Care, Medico-legal cell 1998; page 13-17.
    Legal aspects in medical practice, Dr. S.K.Tiwari, Indian Pediatrics, Vol. 37, No.9, Sept. 2000, page 961-966.
    Medico-legal implications in Pediatrics, practice, Mahesh Baldwa, Ind. Journal of Practical Pediatrics, Vol.6, No.3, page 224-228.
    Textbook of medical negligence, Rajender Singh.
    Joshi M.K. Doctor and Medical Law, 2nd Edn., Ahmedabad 1995, page 4-6.
    IMA News, IMA House New Delhi, Sept. 2001, Vol. 34, page 39.
    Pitfalls and drawbacks in medical notes writing, Dr. Sandhya Khadse, Abstract book Pedicon, 2003.
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