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Business Accent
Legal Aspects of Medical Records
Every physician should maintain the medical records pertaining
to his/ her indoor patients for a period of three years, from the date of commencement
of the treatment.
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 "Patient
has the right to get the medical record pertaining to him and he cannot
be denied the same when he has paid the doctor/ hospital for his treatment
and
hired the services"
- Dr Suganthi Iyer
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Medical records are medico-legal documents and a doctor can
be cross-examined against the same. However, it is a strong evidence of proof
of administration of standard medical care provided documentation is complete.
Incomplete Records Spell Deficiency in Services (Grewal
V/s Chawla)
The respondent, Chawla met with a scooter accident on 26/01/98
and got admitted in the hospital of Dr Grewal. The doctor recorded in his notes
that there was tenderness and swelling of the right shoulder of the patient.
X-ray revealed dislocation of right shoulder for which the doctor performed
an operation of 'open reduction' under general anaesthesia on 28/01/1998 and
discharged the patient on 04/02/1998 and some medicines were prescribed. The
patient was asked to come back five days later on 09/02/98 when the stitches
were removed and was advised some exercises of the elbow and further follow-up
after two weeks. However, as the pain in the shoulder was persisting, he consulted
in quick succession six other doctors and his version was that the doctor did
not perform the operation in a professional manner and that the persisting pain
was due to negligence in performing the operation. He further stated that an
X-ray was taken on 16/03/1998 which showed that a chip of the head of humerus
was lying separate, that the doctor in a malafide manner recorded X-ray as 'ok'
and the separated chip was not rightly placed while performing the operation
and hence the doctor was negligent in performing the operation. The patient
filed a complaint on 11/09/1998 before the District Forum and claimed a compensation
of Rs 3,80,000 on various counts. The complaint was dismissed with the court
holding that there was no negligence or deficiency on the part of the doctor.
The appeal by the complainant was, however allowed by the State Commission,
which ordered the doctor to pay compensation of Rs 1,05,000. The doctor filed
a revision petition against the patient. The plea of the doctor was that he
tried a closed reduction of the shoulder and that he followed the standard procedure
according to the medical texts. However, because of the nature of injury the
closed reduction of the shoulder, although was done, did not work as head of
humerus which was lying away could not be reduced into original position despite
best efforts due to auxiliary nerve damage which was due to the road accident.
Due to excessive bleeding, further attempt of reduction was given up. As the
post-operative period was uneventful and patient was progressing, he was discharged
and advised to do some appropriate exercises. Subsequently, the patient was
advised orally by the doctor that he could undergo at a later stage, a shoulder
replacement surgery. The doctor vehemently argued that the line of treatment
followed by him was correct according to medical texts and established practice.
In cases of bone dislocation, the first thing to be tried is the closed reduction
and if it does not succeed, then an open reduction is to be done. If neither
of these give relief, then a shoulder replacement has to be tried at a later
stage and once again there is no guarantee that the shoulder replacement would
help when there is auxiliary nerve damage. While admitting that there was a
chip and non-reduction of the fractured bone, the doctor clarified that he never
told the patient that his condition was 'ok' and he was completely treated.
It was agreed that there is no material to hold that the doctor was negligent
in treating the patient. However, the doctor did not maintain a proper written
record of the treatment given by him and a rationale for giving such treatment.
Hence, to that extent the courts held, there is deficiency in service.
 The
doctor in his own admission has stated as under—
"I informed the complainant for the replacement of shoulder
when he could not get relief even after doing open reduction. I orally informed
the complainant about the replacement of the shoulder. It is not mentioned in
the discharge card."
In view of the above admission of the doctor, it was held
that it is high time that doctors write correct notes in the operation record
and discharge summary. When information is given orally, it becomes a matter
of debate as to who is telling the truth. It is the patient's right to know
how his case has been dealt with, by the treating doctor. It will also enable
him to follow the treatment prescribed for future and, if required, sometimes,
even to take a second opinion of an expert. It is the duty of the doctors to
state in the record all the details of the treatment given, medicines which
are prescribed and the follow up advice, if any, and given it to the patient
for his reference. Patient has the right to get the medical record pertaining
to him and he cannot be denied the same when he has paid the doctor/ hospital
for his treatment and hired the services. Not maintaining a proper record amounts
to deficiency in service. The cost was quantified at Rs 10,000 in the above
mentioned case.
The writer is Assistant Medical Director Hinduja Hospital,
Mumbai
drsiyerin@yahoo.co.in
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