When should medical records be written

Can I write my notes later ?

I have had doctors bring empty or incomplete files to me of patient who expired and asking me to dictate what should be written in notes. Shocking though this may appear it is not uncommon for doctors to complete the medical records only after an adverse event. Even though they may record the events truthfully but will such records withstand legal scrutiny ? This is a contentious issue between medicolegal experts and many a times I have clashed on stage with Dr Geetendra Sharma, my friend and otherwise an authority on medicolegal issues, over this topic. According to him medical records can even be written upto 24 hours after death of patient. This in my view is hazardous and is in fact against case laws. I feel that medical records should be created as events unfold in real time. Since discussions in conferences get curtailed due to lack of time and this leaves the audience, for whose benefit they are organized, confused.

There is an old Chinese saying “Faintest ink is more powerful than strongest memory”.. Courts expect doctors to create medical records “contemporaneously” as brought out by the recent judgment of Supreme Court in case of Maharaja Aggarsain Hospital vs Master Rishab Sharma. For the sake of good continuity of care, patients’ records should be kept as up to date as possible, which means that information should be added to the patient’s notes as soon as it becomes available. NCDRC in the case of Yashoda Hospital vs D Uma Devi has said that “ The hospital procedure required the monitoring and recording of a patient’s vital signs before and during the procedure…but there were no records of patient’s vital signs during the ERCP procedure”The Commission went on to say that “Doctors must carefully watch for changes in blood pressure, oxygenation, patient reaction, and a myriad of other data. They are required to carefully document the process on virtually a minute to minute basis” The State Commission in the same case had mentioned , “..medical record establishes clear lacuna that there is no recording maintained between 3.30 to 3.50 p.m. on the date of incident”. That the doctors were busy resuscitating the patient and did not have an additional pair to limbs to simultaneously record is but a moot point discarded in the legal dustbin.

A patient of crush injury forearm was admitted at Apollo Hospital Hyderguda and shifted to Apollo Hospital Jublee Hills both in city of Hyderabad with same doctors involved in treatment at both places. The records of patient were lost in transit and doctors created records death / discharge summary of 12 pages from memory and gave affidavits as to the authenticity of the same. NCDRC refused to accept these medical records as genuine. NCDRC in another judgment of Dr Rajani Kumari vs Amar Kant Sharan has stated unequivocally that medical records that are written after the discharge or hours, after death, do not have any legal value. The Medical Records are acceptable as useful evidence by court as per Section 379 of Indian Evidence Act, 1872 amended in 1961, as it is agreed that documentation of facts during the treatment of a patient is genuine and unbiased. Tamil Nadu State Consumer Dispute Redressal Commission recently awarded 57 lacs in a case due to lacunae in medical records as to who and at what time noticed cardiorespiratory arrest, what time CPR was started when the heart was revived. Such details can only be recorded if during CPR the focus is maintained on record maintenance.

There is another issue with records not being written in real time. Relatives at times have taken photographs of the medical records or have snatched the patient file or the police has taken away the documents. This creates problems if doctors later try to complete the medical records opening them to charges of tampering of evidence. In short, medical records should be comprehensive and contemporaneous and it is better to immediately record in file as events unfold rather than rely on memory to update records later.

Dr Neeraj Nagpal

Convenor,Medicos Legal Action Group, Managing Director MLAG Indemnity,

Ex President IMA Chandigarh

Director Hope Gastrointestinal Diagnostic Clinic,

SCO 1066-67 Aerodale Market, New Sunny Enclave Sector 123 Mohali 140301

09316517176 , 9814013735

0172; 2707935, 2706024, 5087794, 9465109935, 9478082176

email; hopeclinics@yahoo.com, hopeclinics@gmail.com mlagindemnity@gmail.com

For Contributions; “Medicos Legal Action Group” Ac No 499601010036479 IFSC code UBIN0549967 Union Bank Sector 35 C Chandigarh;

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