National Consumer Disputes Redressal Commission New Delhi
26 March 2022 at Jabalpur (MP)
To succeed to claim, the C/o has to prove
1. Duty towards patient
2. Deficiency in duty (breach)
3. Directly results- injury (causa causans ) 4. Damage which may be physical, mental or
financial loss to patient or relatives.
“It reflects and creates excellence in medical care.” StandardsofCare:
Documentation is legal protection for both patient and physician in the dispute over care.
Failure to document important details can lead to adverse patient outcomes and malpractice suits.
Ethical issues :
Assures patient confidentiality and ensures that standards of care are met.
Many physicians complain that they do not have the time to write sufficient records!
“Would you rather spend the time in court for 12 weeks, 5 days a week,
from 9 am to 5pm ”
what is important to document
when to document
how to document
how to maintain/destroy
who owns the medical record,
the significance of the transition to the
electronic medical record,
problems and pitfalls when using the
electronic medical record
Use of decorative letter head Over description of doctor’s
qualification /competence (publicity)
Handwriting – wrong dispensing
Explaining to patient
Over prescription of certain drugs (steroid) Abbreviations
Both are separate and distinct concepts.
Consent is generally recognized as a patient
signing a name to a form, or verbally
agreeing to a treatment plan or a procedure. Informed consent is a communication
process that leads to shared decision-making
by the physician and patient.
Physicians are required to obtain informed
consent from patients prior to treatment.
“ Patient’s signature goes a long way toward
mitigating the legal problems of the doctor.”
Reasonable disclosure Adequate disclosure Complete disclosure
Informed consent accommodates both patient autonomy and the physician’s responsibility
Benefits of treatment
Risks of treatment
Alternatives (other treatment options) No treatment (risks of)
Documentation + signature ( Pt+Dr+Witns)
Neatness and legibility Medical transcription
Handwritten notes ▪ Blue ink
▪ Highlight specific items such as allergies ▪ Make corrections properly
Check information carefully
Never guess or assume
Double-check accuracy findings and instructions
Make sure most recent information is recorded
shows list of abbreviations and acronyms used.
MR folder should be clipped or stapled If amendment made- it should be
rewritten by the physician and reason for rewriting should be specified along with signature.
Correct mistakes immediately
Draw a line through the original information
Document why correction was made
Date, time, & initial correction Insert correct information
Hv a witness,if possible
Client’s words Clarity Completeness Conciseness Chronological Order Confidentiality
Neat, Legible,Timely,Accurate, with Professional tone
Referral Note Discharge Note
Confidential Correcting MR
1.3 : Maintenance of Medical Records:
Section 1.3.1 – 3 years from commencement of treatment (IP).
Section 1.3.2- issued within 72 hours of request – to patient or authorized representative
Issue register – date, time, identity
• Referringapatientisnotanegligence • Remember Having a
“second pair of eyes and ears”
help you out of litigation.
Issuing Medical Certificate in Good Faith Advertisement / Unfair trade Practice
Shortcuts; illegible prescription,
Vague reports, Abbreviations
Maintenance/Tampering of Record
Hon’ble Ms Justice Indu Malhotra of Supreme Court of India advises doctors to do „robust documentation‟
Violation of Ethical Regulations 1.3, 7.2 related to Medical Record constitute Gross Professional Misconduct and Deficiency in Service: