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Medical records

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Medical records

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Medical records means and includes the record pertaining to the admission, diagnosis, treatment, investigation, daily progress, operations, consultations

Medical records means and includes the record pertaining to the admission, diagnosis, treatment, investigation, daily progress, operations, consultations

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Medical records

  1. 1. MEDICAL RECORDS DR. ARIF MASOOD PRINCIPAL& PROFESSOR ANANYA COLLEG OF HOMOEOPATHY, KALOL , GANDHINAGAR
  2. 2. DOCTORS AND MEDICAL RECORDS  Medical records means and includes the record pertaining to the admission, diagnosis, treatment, investigation, daily progress, operations, consultations etc.  Importance of Medical Record Medical record is required for patients or hospitals. 1. Medical negligence cases 2. For life insurance policy purpose 3. For third party claims under health and accident insurance 4. As a proof of disability 5. Workman’s compensation cases 6. Traffic accidents cases 7. Follow-up cases or taking treatment from another doctor 8. Medico-legal cases
  3. 3. MEDICAL RECORDS  Medical Record is Required for Doctors/ Hospitals for  1. For medical research  2. For cost accounting  3. Hospital audit  4. Evaluation of drug therapy  5. Planning  6. Legal purpose  7. Administration  8. Follow-up cases  9. Insurance claims
  4. 4. MEDICAL RECORDS  What Constitute Medical Record?  1. OPD cards  2. IPD cards  3. Details of provisional and final diagnosis  4. Treatment record  5. X-ray films/USG report/CT scan/MRI films  6. Laboratory reports  Features  •The medical record should be adequate, appropriate and  complete  • The patient or the representatives have got the right of  access to their medical record.  • Well-maintained medical records will help the doctors  and the hospitals to defend in medical negligence  cases
  5. 5. CONSENT  Definition Consent is defined as free and voluntary agreement, compliance or permission given for a specified act or purpose.  • It is based upon the Latin maxim “volenti non fit injuria” means ‘he who consents cannot complain’. This is founded on two straightforward factors, firstly every patient is best judge of his own interest and secondly no man will consent to what he think is harmful to him.  • There is no official or codified definition of consent.Section 90 of IPC defines consent in negative terms..
  6. 6. VALIDITY OF CONSENT  As per this section, any consent given under the following five circumstances will not be a true consent. The consent becomes invalid if given:  1. By a person under fear of injury or  2. By a person who is under misconception of the facts and person who obtains consent knows or has a reason to believe this or  3. By an intoxicated person or  4. By a person who is of unsound mind or  5. By a person who is below the age of 12 years of age.  • Section 13 of Indian Contract Act states consent as “two or more persons are said to consent when they agree upon the same thing in the same sense”.
  7. 7. VALIDITY OF CONSENT  As per Section 14 of Indian Contract Act, consent is said to be free and voluntarily when:13  1. It is not obtained by coercion/force  2. It is not obtained by fraud  3. It is not obtained under influence  4. It is not obtained under influence of intoxication  5. It is not obtained by misrepresentation  6. It is not obtained from mistaken subjects  7. It is not obtained from mentally unsound persons.
  8. 8. TYPES OF CONSENT  Types of Consent  1. Implied Consent  2. Expressed – it may be  a. Oral or verbal  b. Written.  Implied Consent  • Implied consent is common type of consent observed in medical practice  • Here the consent is presumed (i.e. implied). For example if a patient enter in clinic, it is presumed that the patient has came for examination and consultation. Thus the conduct of patient suggests the willingness to undergo for medical examination.  • The consent is not written but legally it is effective  • The consent is provided for medical examination such as inspection, palpation and auscultation. It does not cover the consent for examination of:  – Private parts  – Vein puncture or injection  – Major intervention or operation.
  9. 9. TYPES OF CONSENT  Expressed Consent  Anything other than implied consent is expressed consent. In other words, an expressed consent is one, which is stated, in distinct and explicit language. The expressed consent may be of following types  A. Oral (verbal) consent  – It is consent, which is given verbally. This method is employed for minor procedures. However, such consent should be obtained in the presence of a disinterested third party for example nurse or receptionist  – Oral consent, when properly witnessed, is of equal validity that of written consent.  – Whenever oral consent is taken, it is appropriate to make an entry in the patient’s clinical record. Such precautions taken may be of use in future if any action is brought on the doctor by patient
  10. 10. TYPES OF CONSENT  B. Written Consent  – Here the consent is obtained in a written format.The doctor should explain the type of therapeutic procedure or surgical operation properly to the patient.  – Written consent afford documentary evidence  – When such consent is obtained after explaining the nature and consequences of the treatment procedure being contemplated, is called as informed consent
  11. 11. COMPONENTS OF CONSENT  In medical practice, consent becomes valid when it involves voluntary-ness, capacity and knowledge.  1. Voluntariness – It suggest willingness of a patient to undergo treatment  2. Capacity – it means degree or ability of a patient to understand the natur and consequences of treatment offered  3. Knowledge – it means, sufficient amount of information about the nature and consequences of disease and/or treatment has been disclosed to patient.  Thus, consent should be always:  1. Free 2. Voluntary 3. Informed 4. Clear 5. Direct 6. Without undue influence/fear 7. Without fraud 8. Without misinterpretation of facts 9. Without threat or compulsion.
  12. 12. CONSENT IS NOT REQUIRED  Consent of the patient or relatives is not required under following circumstances  1. Emergency  2. Notifiable disease  3. Public interest  4. Public health  5. The court order  6. Prisoner  7. Immigrants  8. Medicolegal postmortem examinations  9. Armed forces, if medical examination is statutory requirement
  13. 13. INVALID CONSENT & CONSENT OF SPOUSE Invalid Consent  Consent is not valid when given by  1. Mentally unsound person  2. Blanket consent  3. Consent obtained by fraud, misconception, threat or by force  4. Consent obtained for criminal activity such as for procuring criminal abortion, euthanasia etc.  5. When consent is not voluntary and free. Consent Of Spouse Preferably consent of spouse should be taken in following conditions  1. Termination of pregnancy  2. Sterilization  3. Artificial insemination  4. Donation of sperm/semen  5. Any operation that hampers sexual right of the spouse.
  14. 14. EUTHANASIA (MERCY KILLING)  Euthanasia (Eu=good, thanatos=death)  It means producing painless of a person suffering from hopeless incurable and painful disease.  Types- 1.Active Euthanasia 2. Passive Euthanasia 3. Voluntary Euthanasia 4. Involuntary Euthanasia Earlier no form of Euthanasia was permitted in India, On 9 March 2018 the Supreme Court of India legalised passive euthanasia by means of the withdrawal of life support to patients in a permanent vegetative state
  15. 15. EUTHANASIA - TYPES  1. Active Euthanasia is a positive merciful act, to end useless suffering. I t is an act of commission eg by giving lagre doses of drugs  2. Passive Euthanasia : means discontinuing of life supporting measures to prolong life. This is an act omission.Eg; aloowing person to fast till death, remove of ventillator  3. Voluntary Euthanasia means at the will of person. Use of large dose of Opium or other narcotic drug  4. Involuntary Euthanasia means against the wil of the person eg: person in deep coma, severly defective infant
  16. 16. LAW AND CONSENT  Indian Penal Code (IPC)  1. Section 87 of IPC – Act not intended and not known to be likely to cause death or grievous hurt, done by consent.  2. Section 88 of IPC – Act not intended to cause death, done by consent in good faith for person’s benefit  3. Section 89 of IPC – Act done in good faith for benefit of child or insane person, by consent of guardian  4. Section 90 of IPC – Consent known to be given under fear or misconception  5. Section 92 of IPC – Act done in good faith for benefitConsent and Medicolegal Cases  1. For medicolegal autopsies no consent is required  2. For clinical or pathological autopsy, consent is must  3. For examination of a victim for medicolegal purpose, consent is required  4. For examination of accused for medicolegal purpose, consent can be obtained. But if the accused is not giving consent then examination can be done without his consent
  17. 17. MEDICAL NEGLIGENCE OR MALPRAXIS Medical negligence was previously called as malpractice. Still medical negligence and medical malpractice (or malpraxis)are used as synonymous terms but the terms are not same. Medical malpractice includes other forms of irregular medical practices including unethical acts i.e. the medical practice, which is not fair or is a wrong practice Medical negligence is defined as want of reasonable degree of care and skill or willful negligence on the part of Medical Practitioner while treating a patient resulting in bodily injury, ill health or death.
  18. 18. MEDICAL NEGLIGENCE  Thus in the above definition, there are two important components and for negligence either one condition has to be proved i.e.  Firstly – either there is lack of reasonable degree of care and skill applied by doctor while treating a patient. The want of care and skill results in the bodily injury or ill health of a patient or patient has died due to non-application of reasonable degree of care and skill.  Secondly – willful negligence on part of doctor while treating a patient.
  19. 19. CLASIFICATION OF MEDICAL NEGLIGENCE Negligence is a legal concept, not a medical concept. Negligence is actionable and an action for negligence may be brought against doctor in a civil or criminal court. Thus, negligence can be classified as  1. Civil negligence  2. Criminal negligence. Civil Negligence  • Negligence is a tort i.e. civil wrong  • In civil negligence a patient brings charges of negligence against doctor for monetary compensation for the damages suffered by him.  • For civil negligence cases, a patient has to approach civil court or consumer redressal forum (Consumer court).
  20. 20. CIVIL NEGLIGENCE  Duty of Care  • In case of negligence, it is important for patient to prove that the doctor was duty bound to treat the patient. In other words, doctor-patient relationship was already existed and thus the doctor owes to care the patient.  Dereliction of Duty  • Dereliction or breach of duty means failure on part of doctor to exercise his duty and treat the patient with due care and skill.  • Such breech of duty may be an act of commission or an act of omission.
  21. 21. FLOW CHART OF CIVIL NEGLIGENCE
  22. 22. CRIMINAL NEGLIGENCE  Criminal Negligence  • Here the patient or relatives of patient brings allegation of criminal negligence against a doctor. In criminal negligence, the doctor is prosecuted by the police and charged in a criminal court.  Criminal negligence is gross negligent acts that had caused death or severe harm to the patient. The doctor showed a gross carelessness or gross neglect for the life and safety of the patient.  Criminal negligence is a serious than civil negligence. The negligence amounts to a criminal offense and goes beyond a mere matter of compensation.21 The doctor is liable to be punished under the Indian Penal Code (IPC), example, Section 304-A, 304, 336, 337, 338 etc.
  23. 23. CRIMINAL NEGLIGENCE  Examples of Criminal Negligence  1. Operation on wrong limb  2. Removal of wrong organ  3. Wrong blood transfusion  4. Leaving instruments in abdomen  5. Performing criminal abortion
  24. 24. DIFFERENCES BETWEEN CIVIL AND CRIMINAL NEGLIGENCE Features Civil negligence Criminal negligence Negligence Absence of care and skill Gross carelessness and disregard for patient’s life or welfare Offense No violation of law Violation of criminal law Conduct of doctor Compared with peer group Not compared to single test Consent for act Good defense in court Not a defense Trail Civil or consumer court Criminal court Evidence Strong evidence is sufficient Guilt should be proved beyond reasonable doubt Punishment Liable to pay damages Imprisonment

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