107 medical documentsn-litigations.(daman)

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  • 1. Medical Documents DR. SUBHASH B.BEHERE. M.S.,LLB. PUNE CONSULTING SURGEON & MEDICOLEGAL CONSULTANT. CHAIRMAN, MEDICOLEGAL CELL I.M.A.MAHARASHTRA STATE . SBB -April 04
  • 2. Doctor is Answerable to (separately or jointly)
    • Medical Council
    • Criminal Court
    • Civil Court
    • Consumer Redressed Forum
    • Janata Durbar! (most dreaded)
  • 3. Medical Negligence
    • If a doctor commits any act which other reasonable doctor of his standard would not commit OR The doctor omits to do something which other doctor would certainly do
    • Res Ipsa Loquitor (Gross) : utter disregard for human life
    What is demanded is a reasonable & average care of a prudent doctor in similar circumstances
  • 4. Non — Negligence
    • Difference of opinion
    • Wrong diagnosis in spite of diligence
    • Accidents : detected, attended &
    • managed reasonably in time
    • Unexpected results
    • Misjudgement
    • Professional charges
    More the expertise claimed — more the care demanded
  • 5. Vicarious Liability
    • Whatever is done by the staff
    • Whatever is done by partners, associates (locum)
    • Whatever happens in your premises
    • Defective service, due even to contractor’s problems
  • 6. Prevention of Clinical Medico legal Problems
    • Attention : Additional opinions
    • Behaviour : Bill & Behaviour
    • Communications : Consent &
    • Certificate
    • Documents
    • Expertise ; Efficiency
  • 7. B Bills & Payments
    • Professional bill do not come under the purview of law
    • Prevent displeasure by starting system of advances
    • One cannot detain patient / body for payments
    • With reasonable warning & time, you can discontinue treatment & transfer to Govt. / charity institute
  • 8. C CONSENT
    • Essentials of a valid consent
    • Free consent- without coercion, undue influence, misrepresentation, fraud or mistake.
    • Capacity to enter contract
    • Adult of sound mind -Minor- by guardian
    • Child -7 to 12 years ????
  • 9. Consent
    • Valid consent
      • Competent person
      • Major / guardian
      • Child 7—12 yrs
    • Witnesses — 2
    • Simple / any language / specific / clear / unambiguous
    • Mention common complications / alternatives
    • In emergency...
    • Sterilisation / castration — both spouses
    • Amputation — second opinion
  • 10. C CONSENT
    • Written consent OR Implied consent
    • Informed consent relevant information of illness and treatment has to be explained
    • Significant material risk has to be explained
    • Alternative modalities
    • Unusual or special risks may not be explained
    • Exceeding consent-- Think of Postponement , Operate only if urgent
  • 11. Consent
    • Why doctor should feel shy of informing & taking written statement to that effect?
    • BOLDLY document the non-compliance o f any of your advice
    • Consent of a child after (7) 12 years is a must, along with Guardian’s.
  • 12. C CERTIFICATE- Care while issuing
    • On Letter pad only- Doctor’s Name, Qualification,Address and Registration no.
    • Mention Date, Time, and Place of issue
    • Issue only on demand and for legitimate cause
    • It should be TRUE and CLEAR Without ambiguity
  • 13. CERTIFICATE_Care while issuing- continued
    • Identification mark of the patient and/or The thumb impression
    • Period of illness should be clearly mentioned
    • Keep Duplicate copy
    • You can charge for the certificate (except for the Death certificate.)
    • Diagnosis- Disclosure only after patients express consent unless required by the law
  • 14. Death Certificate
    • NO FEES
    • CONFIRM DEATH PERSONALLY
    • SUSPECED HOMICIDE  INFORM POLICE
    • GET ACQUAINTED TO NEW FORMAT
    • CARDIO-RESPIATORY ARREST ETC. NOT A CAUSE
    • DO NOT ISSUE DUPLICATE
  • 15. Medical fitness “will document”
    • Issue to a known person only , Otherwise confirm identification
    • Take thumb impression + signature of the the person executing the will.
    • Ascertain mental stability of the person.
    • Always put date time and place.
    • Make counter entry by making a formal case paper for your record.
  • 16. D MEDICALDOCUMENTS
    • It is your FRIEND OR ENEMY
    • Aim- Patient’s monitoring
    • Medical Research
    • Students Education
    • Legal- Insurance /reimbursement
    • Courts
    • Research & Statistical study
  • 17. D MEDICALDOCUMENTS
    • Should be -- Clean- Avoid overwriting.
    • Correct and Comprehensive.
    • Chronologically correct - Put date & time.
    • Complete and Confidential.
  • 18. MEDICAL DOCUMENTS
    • Preservation
    • M.L.C. s ----- for ever ( 30 years ) Administrative papers -- Registers etc 10 years
    • Indoor ----- 5 Years
    • O.P.D. ----- 3 Years
    • Identification Mark on paper is important
  • 19. D MEDICAL DOCUMENTS
    • Whose Property -
    • Hospital has right over papers but
    • Should provide copy to court / police on demand OTHERWISE
    • It is a confidential communication and
    • cannot be released without his permission
  • 20. MEDICAL DOCUMENTS
    • Patient has a right to demand it at a reasonable fees and in reasonable time.
    • DO NOT SAY NO TO THE DEMAND
  • 21. MEDICAL DOCUMENTS - Discharge card
    • Short history, clinical notes, summary of
    • operation and/or treatment.
    • Instruction on discharge card HAVE to be more elaborate.
    • Always write to report back date --- etc OR report if----
  • 22. MEDICAL DOCUMENTS - Prescription
    • As far as possible- Neat ,Good hand writing
    • Drugs in CAPITAL LETTERS
    • Strength of medicine must be written
    • Correct dose With clear instructions of frequency of intake.
    • Address and registration No - must
    • Preferably give follow up date
  • 23. MEDICAL DOCUMENTS-Referral Notes and Transfer notes
    • Carbon Copy should be kept.
    • Put Date and time at time of Transfer.
    • Write treatment summary & Your assessment of patients condition.
  • 24. Any -- ?????????? Earnestly Invited from the audience
  • 25. THANK YOU
            • ***********************************
  • 26.