Medico- legal cases- “Safeguards a Doctor Must Know”

By – Dr. Om Prakash Shah Ex-HOD & Sr. Prof. Department of Orthopedics Dr S.N. Medical College Jodhpur(Rajasthan) Prof. Department of OrthopaedicsRohillkhand Medical CollegeBareilly(U.P.)

Introduction• It is quite apparent to all of us that medical practice

today has undergone a dramatic change the mutual faith between doctors and patients has been considerably eroded. court cases has been increased against the doctors. so for safe practice I am presenting some guidelines or precaution to prevent and if occur handle the medico legal of cases(consumer cases), Material - We should consider the following guidelines for safe clinical practice.

Importance of Record Keeping and Documentation of Patient Care.

• This is most important but poorly implemented in our country. • It needs great improvement and willingness to change current practice.• In western countries private practioner employ secretaries for

maintaining record.• But in our country most consultant do not want to spend money for

record keeping and doing restaurant type practice (i.e. People enter, service is provided, payment is received- end of matter).

• Until they face a medico legal problem doctors do not realize the importance.

• Older days has gone when the doctor was a solo practioner who treat everything, dispensed innocuous medicine and needed a very few lab test.

•

• Good medical record keeping is extremely critical to the delivery of good quality medical care.

• – Good medical records are your best defense

against allegation of negligence or medical mal practice. For e.g. in court evidence.

Parts of medical record.

– But now patient records needs to document historical information, i.e. current and previous medical problems, clinical findings, diagnostic tests (pathology, radiology, sonography, scan, MRI). Specialist consultation, treatment, operative procedure, progress report, nurses’ report, final diagnosis, discharge summary and follow up notes.

– It is very clear that treating a patient is teamwork of doctors, nurses, technicians, paramedical staffs etc. Each one of them has complete information about a patient from medical records only and treat patient with confidence and safety. Follow up patient can be treated by seeing old records.

– The following documents forms parts of medical records• Opd record.• IPD record(history, consent form, diagnostic record, referral & prescription slip,

patient case sheet showing daily progress notes, operative notes).• Medical Certificates • Medico Legal reports.• Dying declaration/deposition.• Information to police.

• Good record • Good record means it should be correct, clear,

comprehensive and chronological.• • Uses of Medical Records• Medical Education• Research of incidence, prevention & treatment of diseases.• Audit – Medical, Economic aspects• Medical statistics• It forms legal evidence in judicial proceedings. • It forms base in life LIC claims, workmen compensation etc.

Importance of Good Documentation Record

– Always record time and date of examination (make it habit).• Keep copies of all reports- in MLC absence of investigation

reports hampers an effective defense.• The value of this is realized only in MLC or facing allegation of

malpractice & when you start preparing your defense & discover that all reports are with the patient & you have to rely on your memory or guess work.

• In follow-up when patient misplace their papers you have nothing to treat.

• A mischievous patient (prompted by his advocate) suppresses certain reports which might establish the fact that you were not negligent.

Importance of Good Documentation Record

• Always keep copy of discharge card– It is the final report card of student– It contains

• Date and time of admission• Clinical Findings• Past History• Investigations• Treatment Given• Progress of the patient• Date of operation( operative records)• Complications• Final Diagnosis• Medicines to be taken• Dietary instructions• Follow up instructions• Precautions and follow-up • And most important, the discharge ticket is what the patient carries home.

Importance of Good Documentation Record

• Indoor Case Records- For court purpose whatever is not documented in your notes, never happened regardless of whatever you have actually done.– Continuations Sheet must be numbered, have the name, registration number,

diagnosis, ward and bed number of the patient.– Bed head ticket should be written in clear hand writing.– Alterations as far as possible should not be erased, overwritten or inked out.

Advocates love alterations and create doubts in the mind of the judge. It is better to cut the entry, sign it and write the correct entry alongside.

– Abbreviations can cause confusion. For e.g. PID (Prolapse IV Disc or pelvic inflammatory disease), SCOOR (something coming out of rectum), POOF (Plenty of oral fluids).

• – Consent should be taken in separate paper.

• – On discharge of patient take receipt of documents handed over.

Importance of Good Documentation Record

• OPD Records usually kept in private hospitals or corporate hospitals equipped with computer. In MLC cases the absence of OPD records hampers the defense of the case and we are at the mercy of the patient to provide us the paper. Solution is to keep two copies or computerized record.

• • Proper history taking

– Performa showing no history of diabetes, hypertension, asthma, any operation, accident etc.

– Accurate and systematic history taking will manage health care system and privatization of Health Insurance. Hence get smart make patient declaration Performa routinely. It may save you a lot of botherance some day.

Consent• Take consent even for minor procedure.• Consent should always be in written. Avoid oral consent.• Take consent in patient own language. In MLC patient

advocate make a big issue and patient says that doctor has given me a paper to sign at bottom over dotted line and I don’t know what is written in the form.• Consent should be informed to the patient. In US

without informed consent a doctor will be held liable for violation of patients’ rights.

• Consent must be signed by the patient accept in case of minor, unconscious or semi conscious or mentally unstable patient

Consent• In gradients of informed consents

– Patient understands his medical condition.– Patient understands proper treatment or procedure.– Patient understands alternative treatment.– Patient understands risk/complications of proposed or alternative

treatment.– Patient understands chances of success or failure of proposed treatment.– Patient knows the identity of surgeon.– Disclose any risk of death or serious harm.– Disclose peculiar risk with a specific treatment.– Patient understands the theatre condition. The staff and its efficiency.– Patient understands the availabity of facilities in OT or Hospitals.– Patient understands complications of particular procedure proposed for

his treatment.• • Denied consent should also be recorded. For e.g. you advice

investigations (CT, MRI) and patient refused.

Transferring the Patient

• Give the patient/relatives a few options to shift the patient.

• Proper follow up should be made of patient.• Always keep a copy of transferring notes and

investigation reports.• Make note in your records, the needs to

transfer the patient.•

Documentation and Medical Records• Stationary –

– Writing “This report is not meant for medico legal purpose” or similar quotes on the stationary used is of no help. Every report, prescription, advises can be used in a court of law against the doctor irrespective of such statement. This statement creates unnecessary adverse inference in the court against the doctor accused of medical negligence and hence this practice should be stopped.

– Stationary especially letter pad must be carefully kept, if stolen and fabricated documents prepared, they creates medical negligence and legal problem.

• • Writing:

– Avoid changing ink or pen mid way in writing medical records, as this is projected as manipulation in court.

– Courts draw an adverse inference in case of overwriting, deleting, putting whitener etc. It is advisable to encircle the mistake then write the correct thing.

Legal Position in Treating Accident Emergencies

• Merely not charging patient fees doesn’t give you immunity from being proceeded under the consumer protection Act. (Only those hospitals where free treatment is given to 100% patients even if normal registration fee is charged) are exempt from coming under purview of the Act. So please charge your profession fees, not charging fees do not mitigate your liability.

• A patient who promises to pay you (Though he may not have actually paid you) also enjoys the status of a consumer. Even a patient who does not pay you has the rights of a consumer if other patients in the hospital are being charged.

• It is well established that in a dire emergency or life threatening situation consent of a patient or relative is not required. The attending doctor becomes the guardian of the patient. Hence not having consent in such situation is not considered a valid reason for not treating patient.

• As per SupremeCourt decision in the case of permanand katara Vs. Union of India, The preservation of human life is of paramount importance. Hence an injured citizen brought for medical treatment should be instantaneously given treatment to preserve life. Hence no doctor is expected to refuse to treat a patient in an emergency.

Issuing Death Certificate:

• Issuing a death certificate for a patient brought dead, with no attendants and no personal knowledge of the cause of death, is a for potential trouble.

• It is unwise to issue a DC in order to oblige the relatives. Misplaced sympathy to save post– hassles can backfire once in a way. And just one such case is enough to cause you a lot of trouble.

Intimating Police for Medico Legal Cases• Cases of RTA, Assault and other injury cases, burns, poisoning etc. have to be informing t

o the police as per law. • • Keep Following Points in Mind• Emergency treatment should be given preference. However information to be done as e

arly as possible. Unreasonable delay may call for explanations. Note the time of intimation and when police came, note his Bella number. If you send written intimation then get an acknowledgement. It is not certain that police will not come promptly but at least you have done your duty.

• Whenever police constable complete his formalities make sure that he signs and makes some notation in your case paper in token of having done needful. This is important proof if police denied.

• In RTA always inform police for minor injuries also. • The settlement between accused and victims should be done in front of police. If later o

n dispute occur, police will harass you of not informing police at the time of injury. • Suicide is a crime. Attempting suicide by organophospherus poisons or sleeping pills etc.

must be informed to police in a reasonable time and not later when patients condition becomes critical

• If the patient is saved then refer him to Psychiatrist to prevent further attempt as patient has suicidal tendency. If relatives are unwilling document this in case sheet.

Availability of Emergency Services

• If you stick Board on your nursing home “24 hrs. Emergency services available” make sure this is really the case. Otherwise it may create problem, if someone is not attended and suffer damage.

STAFF LIABILITY• As per the law, an employer is responsible for action of his employees• It is the right; duty and responsibility of the employer supervise the employees. • While selecting staff check their original certificates of qualification and experience and keep t

heir record. Always employ qualified staff although experience but • Note following points...

– Discourteous or rude behavior by your staff members (nurse, 4th class, receptionist, ward boy, sweeper etc) could be the root cause of your allegations, otherwise sound management of the patient. The displeasure of patient against your staff members can be easily directed towards you.

– Your staff represents you. Both credit as well as discredit of their performance will go to you. Whereas a consultant doctor spends hardly a few minutes with the patient, the staff who is with the patient round the clock can make all the difference.

– An unhappy employee can cause you a lot of loss sometimes in the form of medico legal problem.

– Good staff can prevent many problems (including medico legal problems). Good staff should serve as the eyes and years of the physician. Any disturbing behavior of the patient or its relatives should be reported to the doctors. Invariably the staff rapport with the patient and know the innermost thought of the patient. It is wise to take feedback from the staff and take action accordingly. This will happen if you sensitize your staff to this particular aspect.

– Instruct you’re not to act beyond the scope of their duties. This can create sometimes unimaginative problems.

Handling Allegations of Patients

• Don’t ignore allegations of patients – whether oral or written.

• Handle allegations with sympathy, intelligence, tact and firmness.

• Take professional guidance before answering anything in written.

• Make a police complaint in case of physical threat.• It may be advisable to take guidance from your

associates.

Surgery/Procedure/Intervention• Anesthetist must be always involved where it is necessary.• PAC – should be done one day before along with notes.• Anesthetist should put his notes during surgical procedure and write post

operative instructions also.• Postponing surgery on astrological region by doctor is not his defense. If

patient do not gives consent you withdraw the treatment with record.• Complicated surgeries should be done by experienced and skilled doctor of

that procedure. If doctor of that specialty is not available on such day, postpone the surgery.

• Always take high risk consent for surgery from patient with abnormal vitals.• Guess the complications of the surgery and make necessary preparations

for the same.• The principal surgeon will be liable in court for any mistake committed by

any member of surgical team.• Always record pre-intra and post operative notes especially complications.• In case a procedure require multiple session, explain it to the patient with

dates.• Elective surgery should be done only when patient is completely fit.

Surgery/Procedure/Intervention• Surgeon is responsible for post operative care; if he goes on

leave manage other doctor of same caliber.• Stopping surgery mid-way on safety ground is not negligence,

but it should be recorded and informed to the patient.• Leaving any gauge or equipment in the body is negligence. • Specifically inform the patient in case any part or organ is

removed.• Surgical complications if occurred must be informed with a

sense of urgency. • Write post operative instructions.• Post operative infections should be checked and recorded.• In case of deviation from the advised surgery it is mandatory to

record the regions for any such change in the operative notes.•

Insurance Cover for Medico Legal Liability• Ideally safe practice thereby avoiding MLC is our motto. But it is wise to protect

from unhappening MLC by taking Professional Indemnity Insurance.• One should not practice even a single day without insurance. In USA it is

compulsory. Its importance is understood when a legal notice from a patient come to you demanding huge money for compensation.

• Cost of insurance – Rs.2000 for 10 lakhs for one year.• Coverage: It covers against legal liabilities from claims arising of bodily injury or

death of any patient caused or alleged to be caused by your error, or negligence in professional service …

• Categories:– Personal or individual– Errors and omission policy – covers institution, nursing home or hospitals along with its

staff members.– Precautions:

• Fill Form personally, carefully and truthfully. Do not hide the past fact. In omission policy if staff is not qualified then write ‘No’ but fill ‘Trained’. They will take some more premiums.

• Always preserve copy of policy.• In the column AOY (Any One Year): AOO (Any One Occurrence) ratio always opt 1:1 ratio.• Always check retro active dates. Renew policy without single day delay.• Preserve your policy for several years.

Step To Step Guide to Deal with Consumer Forum Notice

• As soon as you received a notice from forum, a variety of emotions occurs like – hurt, shock, anger, humiliation, guilt, always fear and often panic. At this time you need maximum support and guidance. But the fear is imaginary and arise out of having to deal with a situation which is unpleasant. What to do now...

• Note down the date on which you received the notice and forum (District – 20Lakhs, State – 20 Lakhs to 1 Crore, or National - above 1 Crore), because you have to reply within 30 days and also note the date of reply.

• A copy of complaint of the patient usually accompanying the notice. Read it carefully, what are the allegations made against you? If complaint copy is not attached, inform the forum.

• The reply should be drafted carefully after consultation with your association and with an advocate. Also appoint an advocate.

• Now make the summary of events – write in detail the occurrence of the whole story from the time you first met the patient till the present time.

Step To Step Guide to Deal with Consumer Forum Notice

• Reply of the allegations – Generally complaints of patient is prepared by an advocate and is in the form of numbered paragraph. Read thoroughly the complaint and allegations and prepare your own reply or medical explanation.

• Send a copy of the following to your advocate:– Copy of complaints– Summary of events– Reply of allegations

• Now collect medical literature related to your which cause the conflict from text book, journals or internet and send a copy to your advocate.

• Take expert opinion from senior consultant in the form of affidavit.• Your advocate now finally draft the reply which should be submitted to the

forum along with necessary documents within 30 days. You can demand a 15 days extension also.

• Sometimes patient makes allegations against more than one person i.e. surgeon, anesthetist and hospital, and it may happen that instead of replying to the allegations complainant start opposing each other. This must be avoided.

Step To Step Guide to Deal with Consumer Forum Notice

• Summary : If you are having professional indemnity policy in the insurance following actions are to be taken –– Inform insurance company through your agent and medico legal

cell (if any) about the receipt of the notice from a consumer a forum (send notice, complaint and photo copy of your policy).

– Mention the name of advocate who will handle your case.– Ask your claim to be registered and to be notified the claim

number.– Keep informing the progress of case to insurance company.

• A word of caution – Do not neglect the notice of consumer forum once the reply has been filed keep continuously in touch with further developments. In a few cases lack of attention of the concerned doctor have resulted in adverse judgment.

Efficient Dealing with the Patient• The key to good patient rapport is good communication. The

key to good patient communication is listening and because of good doctor – patient relationship medico legal cases can be avoided.

• If patient questions are not answered – it becomes anxiety, resulting into aggration giving anger and this anger will call advocates, social workers, media persons etc. The main importance during patient conversations i.e. (listening and replying i.e. talking). 80% - 90% role is of your body language.

• God has given two ears and one mouth i.e. hear twice than speak.

CONSENT FORM

• I (name of patient) S/O, D/O, W/O, M/O Registration no. – • Age - … Sex - …. residing at - …………………………….. of my free will give my

consent for ................................................. (Name/Type of operation/Procedure ) under…........................ (Type of Anesthesia)

• The risk involved in surgery\procedure and anesthesia have been explained

to me and I accept the same. I understand that the procedure is being done for my benefit. I also understand that the operation/procedure/anesthesia of drug administered may cause some unintended short term or long term complications of disabilities which I accept. I leave extent of surgery to the discretion of the operating surgeon.

• Sign of Patient• No guarantee of my cure has been given to me. About the result of

anesthesia or surgery. • • Witness sign - Sign of patient ……………….

THANK YOU..!!