ABSTRACT
Studies have shown that about 90% of medical litigations could have gone in favour of the alleged doctors if adequate/proper documents were available. In most medical litigations, the accused doctors have done their duty well but failed to document the same on paper. Example: A viper bite case was brought to a government hospital, but the patient was asked to visit another private hospital due to stock ASV. But the medical officer did it all verbally without proper documentation. The patient filed a negligence suit against the hospital two months later, saying she had suffered physically and incurred monetary loss due to non-admission at the government hospital. She also alleged the medical officer did it for a fee split with the referred private clinic. The hospital could not prove the ‘out of stock’ status of ASV on that day.
The usual excuse for poor documentation habits is, ‘I am a doctor. My time should be more for the patient than for the papers.’ Well, this logic can save the patient but cannot save the doctor from his patient. Litigant patients do not come with a label on their foreheads.
Most medical practitioners are usually poor in documentation, are poorest in record-keeping, and have crude hearsay knowledge of medical certification. Documentation and communication alone are sufficient to prevent about 98% chances of medical litigation against doctors.
Medical documentation and record-keeping have hardly ever been a serious topic for doctors or undergraduate medical students.
This chapter on medical records has been tailored, keeping in mind all the basic requirements that a medical man must be mindful of during his clinical practice. The most adored highlight of this chapter is the ‘Clinician’s Corner’, which includes a compilation of replies and queries related to the legal problems or practice-related issues of clinicians received during my legal medicine consultancy. This section also contains questions from medical students and paramedics as well.
