Medical records

Delhi High Court on Monday observed that the medical reports led by the jail doctors should be explicit and must explain the complex medical terms used not just in medical jargon but also in simple language. The Court also observed that such medical reports must clearly state the history, examination ndings, clinical diagnosis and its interpretation in simpler terms thereby assisting the judges and the Court in an effective manner.

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While observing so, the Court also advised the doctors to be “more cautious” while granting medical certi cates for the purposes of submitting them as evidences before the court of law.

A single judge bench comprising of Justice Subramonium Prasad observed that any “sketchy, wishy-washy medical documents” from any random private doctor having “ambiguous and incomplete documentation in illegible handwriting” will not be entertained by the Court in the future.

    

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Furthermore, the Court also went ahead to observe that in case any attempt is made

by “questionable private doctors” to prolong or use lame excuse by taking help of unambiguous medical documents and in the event of submitting such sketchy medical reports, must be guilty of an offence under sec. 192 of the Indian Penal Code providing for “fabricating false evidence”.

“Applications on medical grounds are now being made as a ruse to get interim bail and then prolong it for inde nite periods even though it is not required and thereby taking the Courts for a ride.” The bench observed.

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The observation came in a case challenging the bail granted to an accused on medical grounds due to “sketchy medical reports” given by jail authorities while granting bail.

“It is found that that the medical reports which are led by the Jail Superintendants are not clear and the medical terms which are used are not easily decipherable by Judges. The Reports do not bring out the correct picture and sketchy and incomplete reports are given by hospitals/doctors which are being used for grant of bail or extension of bail.” The Court observed.

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The accused was granted interim bail by the Additional Sessions Judge after submitting that he was suffering from various ailments and critical tumour in the

     

chest as a result of which he was not in a position to breathe properly.

The Court while considering the two medical reports dated 4th November 2020 and 23rd November 2020, it was observed that the Fine Needle Aspiration Cytology (FNAC) conducted by the jail hospital showed that it was the case of simple gynecomastia which means that there was no tumour and the same must have been clari ed in the medical report, which was not done in the case.

“When an FNAC in the jail hospital itself has ruled out any tumour, let alone any malignancy, and it has also ruled out any infection like TB, the medical report set to the same ought to have clari ed that there is no tumour or malignancy as that operation was only for mere cosmetic purpose and not a medical emergency. Absence of such a clari cation in a medical report does not assist the Court, rather the report conceals vital information from the Court.” The Court observed at the outset.

Manner of Status Reports to be Filed by Jail Doctors

The Court observed that the status reports led by jail doctors must be explicit, explaining the complex medical terms not only in medical jargon but also in simple language.

“The doctors preparing the Status Reports must clearly give their nal impression and opinion as to whether the condition warrants any urgency/emergency. Further, the Status Report must explicitly state if the condition of the patient is likely benign/malignant/infective and state clearly whether surgery is needed for that speci c condition or not.” The court observed.

Furthermore, it was also observed by the Court that reports from many private hospitals do not disclose the correct diagnostic terms which can be appreciated by

 

the judge who does not belong to the medical background. Opining thus, the Court held “Sketchy, wishy-washy medical documents from any random private doctor with ambiguous, incomplete documentation in illegible handwriting will not be entertained in future, rather viewed seriously with suspicion.”

Setting out the contents as to how medical reports must be submitted by Jail Hospitals, the Court held that such reports must clearly state, rst, what is the diagnosis; second, Whether it can be simply treated by giving medical treatment in the Jail Hospital and third, If there is any urgency and if it is an emergency then the nature of emergency must be clearly mentioned.

In case where the patient is referred to a referral hospital, such reports must state the diagnosis in simple interpretation, whether the disease is treatable and with what emergency surgery and whether any investigation is required to be performed in the jail hospital.

Procedure Where Medical Reports are Ambiguous and Create Suspicion in Judge’s Mind

The Court also noted that in a case where such reports create suspicion in judge’s mind on account of it being ambiguous, such reports must be sent for scrutiny by a Medical Board consisting of two-three specialists from a government hospital so that they can endorse or refute such document and if it is found that the reports are only made to prolong the period of bail then, such report should be viewed seriously by the Court, which must consider initiating appropriate proceedings.

“Advantage is being taken of the fact that Judges are not medical experts and are therefore unable to correctly appreciate the nature of the ailments. The accused try to get their bail extended even though they are not suffering from

 

any serious ailments which require them to be released on interim bail.” The Court observed.

Private Doctors Submitting Sketchy, Wishy-Washy Medical Reports Are Guilty Of An Offence Under Section 192 IPC

Observing that ling sketchy medical reports will be viewed seriously by the Courts, the Court went ahead to observe that such doctors are guilty of committing an offence under sec. 192 of IPC which talks about fabricating false evidence.

“All this leads to a lot of suspicion of a foul play and of ambiguity and can lead to serious doubt as to whether any procedure was at all done in the private hospital in good faith. A serious note is taken of such skimpy, wishy-washy medical documentation and the licence of such doctors should be cancelled if found to be lacking/falsely done.” The Court observed at the outset.

Furthermore, the Court observed “All this reeks of several lacunae at several levels including the medical personnel both at the level of jail hospital and the private doctor’s level.”

Click Here To Read Judgment

 

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