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Documentation Mistakes made by Doctors :Dr Sharda Jain / Dr Jyoti Agarwal
- 2. Documentation Mistakes madebyDoctors D.G.F. Medico Legal Cell DR. SHARDA JAIN DR. JYOTI AGARWAL
- 3. AN OUNCE OF PREVENTION IS WORTH MORE THAN A TON OF CURE !
- 4. PRINCIPLE • DOCTOR,s WORK IS NOT FINISHED TILL PAPERWORK IS DONE both in OPD /IPD • “ THE THING WHICH IS NOT DOCUMENTED HAS NEVER HAPPENED “ JUDICIARY THINKS THIS WAY.
- 5. BETTER BE SAFE THAN FEEL SORRY
- 6. ALL aspects of DOCUMENTATION • What is document • Why to keep D • What to D • When to D • How to D • Whereto keep D • How long to keep D • How to destroy D Whose Responsibility Characteristic of GOOD D What to give to patient Confidentiality to whom to hand over patient Medical Records
- 7. What is DOCUMENT/ Evidence • Ant matter expressed ,figures or marks for purpose of recording your treatment. • * a writing is a D • *A PLAN is D • * An inscription on Metal plate /stone is D • EVIDENCE : all statements ORAL /WRITTEN case records.
- 8. WHY TO KEEP DOCUMENT • “GOOD RECORD IS GOOD DEFENCE” • POOR RECORD MEANS POOR DEFENCE • NO RECORD MEANS NO DEFENCE “ • A DOCTOR is bound to produce records • IF NO RECORDS Adverse inference • PUNISHABLE-PC-PNDT act form F ,G
- 9. WHY TO KEEP DOCUMENT • Record SPEAKS of Treatment done • Communication can be done about case • Medical audit • Legal protection • REFLECTION OF QUALITY OF CARE • POOR RECORDS POOR DEFENCE • NO RECORD NO DEFENCE Many k Judgments
- 10. CASE: PAPERS SUBMITTED FROM A T Z except consent papers Lawyer pleaded : operation was done without consent doctor was shocked Consent submitted later with patient signatures but not entertained by court
- 11. GOOD RECORDS ARE INDISPENSABLE / OUR BEST FRIENDS IN THE COURTS
- 12. OUR 2 LEGS TO STAND IN COURT YOU FEEL SORRY BUT TOO LATE
- 13. GOOD V/S BAD DOCUMENTATION Famous kunal saha case The detailed record maintained by Beech candy hospital bombay saved them from the civil suit filed against them. While poor documentation created problems against AMRI hospital kolkata Highest litigation Amount 6.5------11.5cr
- 14. Summary of Importance of Med. Documentation • “It reflects and creates excellence in medical care.” • Standards of Care : Documentation is legal protection for physician in the dispute over care. Failure to document important details can lead to adverse patient outcomes and malpractice suits.
- 15. Importance of confidentiality in Med. Documentation • Ethical issues : Assures patient confidentiality and ensures that standards of care are met. • DETAILS can,t be revealed to husband too • NCDRC :LAND MARK DECISION
- 16. CURRENT SCENARIO OF RECORD KEEPING OF PATIENT CARE in INDIA ? DISMAL WESTERN WORLD SECRETARIES PREPARING ,STORING ,RETREIVING INDIA LOW PRIORITY
- 17. OPD CARE : RESTAURANT-TYPE PRACTICE
- 18. NO TAKERS RECORD KEEPING COSTS MONEY /TIME EXTREMELY SKETCHY & SHABBY 99% DR MEENAKSHI SHARMA APP
- 19. 1.DOCUMENTATION of Case papers Doctor Job 2.MAINTAIN & KEEP RECORDS Safely HOSPITAL RESPONSIBILITY
- 20. WHAT TO DOCUMENT • Both OPD / IPD case papers are to be prepared & preserved as per Central Clinical Establishment Act OPD case papers need to be preserved • Chronology of OPD CASE PAPERS: registration ,complaint in patient language /Exam /Provisional Diagnosis / lab test FINAL DIAG PRESCRIPTION (GENERIC NAMES of Medicines / Counseling /Consents
- 21. CHRONOLOGY OF INDOOR case papers HOSPITAL RECORDS MEDICAL ( PATIENT & HOSPITAL related ) Records (16-17 registers)
- 22. DOCUMENTATION the thing which is NOT documented has NEVER happened • CORRECT • CLEAR • COMPREHENSIVE • CHRONOLOGICAL • CONTEMPARANEOUS IT IS HIGH TIME ,WE GIVE IMPORTANCE TO OPD/IPD RECORDS +consents 50% Litigations Avoided
- 23. NO DOCUMENTATION Blank CONSENT DASH…… SAB KHALI Court : 10 LAC +
- 24. TAMPERING FOGERY BIG OFFENCE APPOLO HOSP 1 CRORE + 1O LACS Suhani Verma’s case
- 25. Doctor’s liability Civil liability Criminal liability How Long To Keep Records ? NEGLIGENCE: Act of omission/ act of commission 3 YEARS e.g. UPT + AFTER TL RAKHANA HEE HAIlifelong 10-15 YRS
- 26. HOW LONG TO KEEP RECORDS ? MTP Act (Section 5.1) 5 years Pndt Act (Section 29 & Rule – 9.6) 2 years BMW Act 5 years Income Tax Act 8 years ICMR Guidelines – ART 10 years – national Registry Surrogacy Bill 25 years Consumer protection Act 2 years Civil Litigations 3 years Criminal laws No limits Medical Counseling Act 3 years FOGSI Guidelines 5 years
- 27. MCI Indian Penal Council (MCI ) ( code of conduct , Etiquette ,Ethics ) • If Request is made give records in 72 hours • Not providing records on written demand by authorized person within 72 hrs amounts to deficiency in service & Negligence NCDRC (2008 MS Lok Nayak jai praksh hospital + Many more cases
- 28. Complainant has to prove : 4D To succeed to claim, the C/o has to prove 1. Doctor,s Duty towards patient 2. Deficiency in duty (breach) 3. Treatment Directly resulted in injury (cause causans ) 4. Damage which may be physical, mental or financial loss to patient or relatives COMPENSATION IS INVARIABILY GRANTED BY COURTS ( death / organ loss /mental torture )
- 29. COMMON Mistakes in Medical Records (MR)
- 30. Common Grouse of Doctors • We do not have the time to write sufficient records! • “Be prepared to spend the time in court for atleast 12 -20 times from 9 am to 5pm ” Choice is yours
- 31. WHAT TO DOCUMENT ? • DATE /time /details /full signature /name in capital letters/stamp • Short signature without capital name NOT Valid • Chronology /every document to be signed by responsible person • Discharge slip to be signed by treating doctor • OPERATION Notes to be signed by surgeon • DOC COMPLETED in reasonable time
- 32. WHAT TO DOCUMENT ? • NO DISCRIPANCY • HANDWRITING—Legible ,could be deciphered • PROPER PAGING • PUT CHECKLIST IN END BEFORE SENDING TO MRD / MRD PERSON again should recheck. • Patient refusing / non cooperation should be documented /witness
- 33. Need to understand • What is important to document e.g. operation notes : trend of sr doctors Hysteroscopy done / NADkam nahee chalega xxx Hysterectomy done xxx Lap cholecystectomy done details of operation must be written ADVERSE JUDGEMENT- Many Cases
- 34. Need to understand • WHEN TO DOCUMENT reasonable time / Not very late • no point documenting after patient is discharged or died no legal value.
- 35. ENSURE THAT THE RECORDS are completed once EMERGENCY is over BLOOD TRASFUSIONREACTION / DIC DOCTOR BUSY WITH PATIENT PHYSIAN also came –NO NOTES for 3 hours KERALA STATE CDRC-2012
- 36. Landmark Judgment: on NAD / NOT GIVING RECORDS Maharaja Agresen Hospital V. Master Rishabh Sharma (2020) 6 SCC 501. • Hon’ble Ms Justice Indu Malhotra of Supreme Court of India advises doctors to do “robust documentation‟ preterm baby ///retinopathy of Prematurity 9 ROP /RLF ) FUNDUS NAD • Violation of Ethical Regulations ( giving records ) 1.3, 7.2 related to Medical Record constitute Gross Professional Misconduct and Deficiency in Service:NCDRD
- 37. Pearls of Wisdom on documents • DATE /TIME /FULL SIGNATURE /NAME IN CAPITAL LETTER • NO DISCREPANCY OF TIMEYOURS /NURSES /VISITING CONSULTANTS • This is checked meticulously by experts THINGS NOT DOCUMENTED / written as NAD EXPERTS presume HAS NEVER HAPPENED ,never done (NCDRC 2004 ) ,KERALA SCDRC 2012
- 38. MRD / Destroy • MEDICAL RECORDS MRD room MANDATORY CEA • the transition to the electronic medical record is happening • problems and pitfalls when using the electronic medical record- in courts /hard copy is needed • DESTROY : CLEAR GUIDELINES OF MCI -3 YRS /PC – PNDT/Fogsi • Add in 2 NEWS papers ,1 vernacular paper
- 39. Mistakes with Prescription • Use of decorative letter head • Over description of doctor’s qualification /competence (publicity) MCI appoved Qualifications only . • BAD Handwriting • wrong dispensing name /dose • NOT Explaining to patient • Over prescription of certain drugs (steroid) • Abbreviations dangerous!
- 40. Consent and informed consent • Both are separate and distinct concepts. • Consent is generally recognized as a patient verbally agreeing to a treatment plan or a procedure. • Informed consent is a communication process that leads to shared decision-made by the physician and patient. • Physicians are required to obtain informed consent from patients prior to treatment.
- 41. PROPER INFORMED CONSENT • NO Colum should remain unfilled • Signature on dotted lines…!!! Is offence “ Patient’s signature goes a long way toward mitigating the legal problems of the doctor.” • Consent should involve Degree of disclosure KITNA BATAYE ??? Reasonable disclosure Adequate disclosure Complete disclosure
- 42. informed consent/counselling BAHUT JAROORI HAI 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)
- 43. Appearance , Timeliness & Accuracy of Records • DATE & TIME • Neatness and legibility • GOOD to keep copy of discharge card • Handwritten notes * Blue ink * Highlight specific items such as allergies * Make corrections properly art to be learnt
- 44. Accuracy of Documentation • Check information carefully • Never guess or assume • Double-check accuracy of findings and instructions • Make sure most recent information is recorded
- 45. Points to remember for GMR • File 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.
- 46. How to Correct Patient Records? • When mistakes happen, correct them immediately - Draw a line through the original information * It must remain legible - Insert correct information above or below original line or in margin - Document why correction was made - Date, time, and initial correction - Have a witness, if possible
- 47. The 6 C’s Good Med Record 1. Client’s wordsprim infertility xx 2. Clarity 3. Completeness 4. Conciseness 5. Chronological Order 6. Confidentiality Neat, Legible,Timely,Accurate, with Professional tone
- 48. Be Careful
- 49. Finally Avoid • Issuing Medical Certificate in Good Faith • Advertisement / Unfair trade Practice • illegible prescription, • No Opd records • Abbreviations • No operation notes /NAD in Records • Tampering of Record
- 50. NO INSURANCE CO CAN HELP YOU IN MAKING DOCUMENTS PROPER DOCUMENTS ARE YOUR RESPONSIBILITY AUDITING is must : MEDICO LEGAL EXPERTS INTERNAL AUDITING
- 51. Take Home Pearls
- 53. Patients Record are confidential do not discuss without purpose
- 54. Court Believes your Documents only Documents need completion by YOU
- 56. My teacher told …. Best Policy to reduce litigations is
- 57. My GURU also told Documentation saves you from many Litigations and saves our job
- 58. • Fondly known as Teacher of Teachers • Mentors of many of her students / colleagues • Great Gynaecologist , A class surgeon & IVF Expert. • Director Lifecare centre & IVF • Founder & Secretary general of Delhi Gynaecologist forum , a body of over 2500 members . • NMC / MCI : Ethical committee member ,an apex body of 10 lacs modern Medicine doctors since 2018 • Business World : Included her in Top 20 Most Influential women in Healthcare in INDIA • DMC Expert since 2009 to till date • Passionate medical activist..has given leadership role in removing Female Foeticide , Movement of Anaemia, Save Uterus Campaign, and Every Mother Counts etc. • Given concept of JANANI SURAKSHA YOJNA & ASHA WORKER to GOI. • Spearheading movement of Doctors safety / zero tolerance to violence against DOCTORS & Unity of North India Gynaecologists • Decorated with many Lifetime achievement & Living Legend Award from many bodies including LHMC AA, FOGSI ,DMA ,DGF , WOW India Dr. Sharda Jain M.D. (PGIMER), MNAMS,FICOG,FIMSA,DHM, QM &AHO PGDMLS (SYMBIOSIS)
- 59. कानून की पाठशाला D.G.F. Medico Legal Cell