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MEDICAL RECORDS FOR DOCTORS

Importance of maintaining records in medical profession need not to be over-emphasized. Most of the doctors are fully aware that records are a must for medico-legal and income-tax purpose. In addition to these reasons, records have assumed more importance and significance because of application of Consumer Protection Act to medical profession. However, doctors because of their busy schedule,, either don't maintain records of keep very brief, incomplete, cryptic records which are of no use in court matters. With the number of consumer cases against doctors increasing very rapidly, doctors should take all precautions for their defence and one of the most important defence tool is a detailed record of each and every patient. The author would like to invite attention of doctors to the following points, which explain the importance of medical records :

  1. Consumer Forum considers following questions :
    1. Whether there was any negligence on the part of the doctor?
    2. Whether the negligence has caused any injury or loss to the patient?
    If the answer to both questions is in the affirmative, the patient is entitled to compensation.
  2. In Consumer Forum, patient gives his version of events, either from his memory or whatever records in his possession.
  3. Doctor has to defend himself and give his version. Since the time interval between treatment of case and actual case in the consumer forum can be even upto 2 years, doctor cannot & should not depend upon his memory. His version should be supported by records.
  4. Courts generally believe in doctor's records if the records apparently appear to be genuine. However, attempts should not be made to "create" records afterwards.
  5. Patients, if treated 'FREE' are not 'consumers' and are not entitled for compensation under CPA. Therefore, if patient is treated free, it should be clearly mentioned. Some doctors do not keep records of FREE cases. Since free treatment is an important defence, records should be maintained even in case of free patients.
  6. It must be remembered that compensation is awarded in case of negligence and not for expected/unexpected complications or error in diagnosis.
    Negligence is defined as Failure on the part of doctor to render resaonable and average service to the patient, which a prudent medical practitioner having similar qualifications would have given under similar circumstances.
    A case was referred to a pathologist who after bone marrow examination opined that patient was suffering from Hodgkin's Lymphoma. Patient was treated with Endoxan for 56 days. Endoxan was discontinued after advice of another cancer specialist. Patient on her own approached another Oncologist who opined that there was no evidence of Lymphoma and patient was suffering from renal failure. Kidney Transplant was done but patient dies because of rejection of kidney. Patient's husband asked for damages claiming :
    1. Negligence on the part of the doctor and the pathologist.
    2. Death occurred due to Endoxan being given unnecessarily.

The Forum held :-

  1. Doctor who was treating the patient initially had carried out renal function tests which were normal, No negligence on his part.
  2. Pathologist who has preserved the slides has given opinion based on his knowledge and experience. Even if another pathologist gives different opinion on same slides, difference of opinion does not amount to negligence.
  3. It has not been proved that death has resulted because of Endoxan.

Claim for damages rejected.

This case has been discussed to highlight two points:

  1. Difference of opinion or error in judgment does not amount to negligence.
  2. Doctor and pathologist were proved not negligent because they had maintained and preserved their records.

This proves that records are a must and help you if maintained properly in case of legal trouble. Doctors should, therefore maintain records in their own interest. Following types of records are to be maintained.

Though model tabulated forms of various records have been given in this article, the tables should be suitably modified, as and when required.

1. Outdoor Patient's Daily Register

This is a must for all doctor's whether family physicians or consultants. The table give below is self explanatory.

Additional information like general condition of patient whether critical, under influence of alcohol, rowdy behaviour etc. should be noted.

2. Family Register/File/Computer

In addition to daily register of out-door patients, it is advisable to maintain family Register of each family. Doctor can maintain a register or a seperate file for each family. If a doctor is having a computer the information can be fed in the computer. The register/file or computer should include following information :-

  • Name of Head of the family.
  • Age, Sex.
  • Occupation and Income.
  • Business of Office Address with Telephone Numbers. if any.
  • Residential Address with Tel. No., if any.
  • Family Member's information as follows.

3. Indoor Patient's Register

This should be maintained in addition to the patient's file of case papers. A model specimen is given below :-

  • Time of admission is very important. In a recent case decided by National Commission, a patient had claimed that though he was admitted at 2p.m. he was not treated till 3.15 p.m. However, he could not substantiate his claim.

4. Indoor Patient's File

This file should contain :

  • Case papers right from the day of admission. The first case paper should have information like patient's name, age, sex, occupation, address, tel. nos., date and time of admission, provisional diagnosis, condition of patient etc. If patient is critical obtain relative's signature on case paper.
  • All examinations carried out and positive findings.
  • Investigations carried out and their report.
  • Date and Time of daily check-up. If patient is critical, doctor visits the patient three, four or even more times daily. All such visits & timings & findings should be clearly mentioned.
  • Vital parameters like temperature,, pulse, rate, respiration rate, urinary output, food/liquid intake, blood pressure etc. must be noted.
  • If nothing special is found in your check-up or follow up, write down patient's general condition is good and patient has no complaints.
  • When patient is discharged, he should be given a discharge card containing summary of his illness, investigations, operative procedures, if any, treatment given, date and time of discharge, follow up treatment advised, diet and exercise advised and date for next check-up advised. All these details should be mentioned in patient's file.
    If a patient is leaving the hospital 'against medical advice' it should be mentioned in patient's file and also on discharge card and his signature should be obtained for the same.
    Similar procedures should be observed if a patient is transferred to another hospital.

5. Referrals

If a patient is referred to another doctor or hospital it is advisable to keep a carbon copy of your reference letter, more particularly, in medico-legal cases. Name, age, sex of the patient, date and time of consulting, positive findings, treatment given should be mentioned in reference note. Patient's or relative's signature should be obtained on carbon copy.

6. Investigations

Patient is usually referred for investigations like Pathology, Radiology, Sonography, CT Scan etc. on printed reference books provided by the concerned consultant. However, all the details like investigations advised and name of the Pathologist / Radiologist etc. should be mentioned in your records.

7. Consent

Consent is a must for various procedures and operations. It a patient dies after operation, doctor can be charged for murder if consent has not been obtained. If, however, doctor obtains consent before operation and in case patient dies after operation, doctor will not be charged in criminal court. This does not mean that consent gives blanket immunity to the doctor. Consent does not and cannot give any protection in case of negligence.
If a patient refuses to give consent, it should be clearly mentioned and patient's relative's signature should be obtained because burden is on the doctor to prove that consent was refused.

8. Receipts

Recipes are very important for court as well as income-tax purposes. Receipt book should be printed, should have serial numbers and be in duplicate.
No false receipts should be issued to satisfy greed of unscrupulous money - makers.

9. Certificates

Certificates are required to be issued for various purposes like sickness, physical fitness, medico-legal cases, death certificates etc. Following points should be remembered before issuing certificates :

  • A complete record of patient's name, age, sex, diagnosis, treatment, investigations advised, referrals, if any duration of treatment should be maintained. The certificates issued should be correct in all such respects.
  • Date of issue, nature of illness, duration of treatment should be clearly mentioned in the certificates.
  • Patient should be thoroughly examined before giving certificate.
  • It is advisable to issue illness certificate and fitness certificate separately. Proforma is given at the end of the article.
  • Charges received should be mentioned clearly and correctly, if required.
  • Write your registration number.
  • Inform police in case of medico-legal cases. Keep record of the same.
  • Attend courts, if summoned.
  • Tubectomy, Vasectomy of MTP (Medical Termination of Pregnancy) certificates are valid only if issued by an authorised doctor who has received special training in family planning operations. Government does not give any compensation if operation is carried out by unauthorised doctor.
  • Do not give death certificate unless the diseased is under your treatment at least 14 days prior to his/her death.
  • Do not give death certificate in suspected, homicide, unnatural death, suicide etc. Insist on post-morterm.

10. Information to Police

IT is moral and legal duty of a doctor to inform police (and keep record of the same) in following cases :-

  • Suspected homicide.
  • Unnatural deaths like drowning.
  • Road accidents and emergencies.
  • Suicide attempts.
  • Operation Theatre deaths
  • If patient dies withint 24 hours of admission in hospital.
  • Death of women from burns, drowning, poisoning, injuries in less than 7 years of marriage.

11. Non-Co-operative Patients

Doctors sometimes do come across non-co-operative patients, who refuses to co-operate with the doctors in following ways :-

  • Refusal to continue treatment.
  • Change the doctor.
  • Refusal to undergo investigation.
  • Refusal to undergo an operation.
  • Leave the hospital against medical advice.
  • Refusal to allow post-mortem.
    In such cases, record of the same along with day, date, time, etc. should be maintained.
    Last, but not the least,
    Remember, your record is your best friend and best defence in the court, if maintained properly and honestly.