Case Law: Importance Of Keeping Medical Records; An Unisgned Medical Record Is No Defense Poor Record Is Poor Defense And No Record Is No Defense

MEDICAL SUPRINTENDENT LOK NAYAK JAI PRAKASH NARAIN HOSPITAL & ORS. V/S. K.M. SANTOSH. (FIRST APPEAL NO. 244/2008)

ORDER DATED: 14.03.2016

Brief Facts:

The Complainant, who is the father of a minor girl aged 11 years filed a Complaint before the State Commission, seeking a compensation of Rs. 10,00,000, on account of the medical negligence. He has alleged that the patient was suffering from headache was taken to Lok Nayak Jai Prakash Narain Hospital, New Delhi on 29.01.1996 and admitted as an Indoor Patient in the unit of Dr. P. Chaudhury. He further alleged that despite undergoing several tests and taking medicines, the doctors of the said unit could not diagnose the Patient’s disease properly and gave her wrong medicines, which affected her eyes and she became blind.

Thereafter, due to the wrong injection, which was given in the left leg at the same place where glucose was administered, the said leg had turned blue and gangrene developed, on account of which it was amputated.  The father of the girl faced severe financial problems and his daughter suffered mentally and physically, and hence filed a Complaint before the State Commission.

Defense Of The Doctor:

• It was contended that the patient was admitted initially at RML Hospital twice and was given the same treatment, which had given some relief.  Also that the Patient was cured of her primary disease, which was not diagnosed at RML Hospital and was then brought to their Hospital
• They stated that the Patient was suffering from headache and averred that the investigations done showed that the cause of headache was due to Neurocysticercosis (Cysticercal), which is a type of parasitic infection, with Encephalitis (inflammation of the brain).  This was diagnosed by the efforts of the Unit Doctors on the basis of costly investigations like MRI, which was arranged free of cost to the Patient
• The Patient unfortunately had extensive Neurocysticercosis with Encephalitis, which is a life threatening condition and she survived only because of appropriate treatment done by the Doctors and the paramedical staff
• It was further contended that blindness is a known complication of the disease and that MRI report had also shown cysticerci in the orbit bilaterally (both eyes), which raised intracranial pressure.  Because of the critical nature of the disease, the Patient required intravenous glucose and several other injections, including Mannitol, for a long period of time
• That the disease process, development of ulcer in a semi-conscious patient and fluids and injections, all contributed to emergence of dry gangrene, for which amputation was required
• They denied that there was any negligence on their behalf and submitted that Neurocysticercosis is not common in children, which unfortunately the Patient had contracted and became disabled

Court Held:

• The State Commission taking overall view of the matter and the fact that the young girl has to now live the whole life not only as a blind person but also with one leg, as she lost one leg also due to dry gangrene, ordered the doctors to pay a compensation of Rs. 5,00,000
• Being aggrieved by the said order, the doctors filed an appeal before the National Commission, whereby the Commission upheld the award of State Commission to pay the compensation of Rs. 5,00,000, on the grounds of serious lacunas on part of the Hospital in maintaining records
• The Court observed that the MRI and CT Scan Reports were not filed on record. Also, there was no mention of prior treatment in RML Hospital. The doctors failed to give any reasons for development Pseudomonas, a common hospital derived infection, as well as medication for this infection, was also not mentioned
• There was no medical literature filed with respect to how a hospital derived infection like Pseudomonas had developed; what was the treatment given for such infection; it was not clear if the informed consent was taken and the prognosis was explained to the Complainant; and the reasons for development of gangrene, which led to the amputation of the left foot, as the same are not substantiated by way of any documentary evidence.

Hence it is crucial to understand the importance of the Medical/health records as they are a written collection of information about a patient’s health and treatment, they are used essentially for the present and continuing care of the patient.

The Hon’ble Supreme Court and the National Consumer Commission in various judgments have held the hospitals/doctors liable for medical negligence for non-production of medical record as it is the primary responsibility of the hospital to maintain and produce patient records on demand by the patient or appropriate judicial bodies. However, it is the primary duty of the treating doctor to see that all the documents with regard to management are written properly and signed. And an unsigned medical record has no legal validity.

Points To Remember While Issuing Medical Records

Medical Certificates:

• Medical certificate should be on doctor/hospital letter pad
• Date, time, and place should be mentioned
• Issue it only for legitimate purpose and only when necessary
• It has to be true and clear without any ambiguity
• There should be an identification mark of the patient, preferably a thumb impression
• Period of illness should be clearly mentioned
• Diagnosis disclosure of the diagnosis should be only after the patient’s express consent, unless required by the law
• Doctor should maintain the duplicate copy of every certificate
• Request for medical records by patient or authorized attendant should be acknowledged and documents should be issued within 72 hours
• Under the provisions of the Limitation Act, 1963 and Section 24-A of the Consumer Protection Act 1986, which dictates the time within which a complaint has to be filed, it is advisable to maintain records for 2 years for outpatient records and 3 years for inpatient and surgical cases. However the provisions of the Consumer Protection Act allows for condoning the delay in appropriate cases. This means that the records may be needed even after 3 years.