Medical Documents DR. SUBHASH B.BEHERE.    M.S.,LLB.  PUNE CONSULTING SURGEON  & MEDICOLEGAL CONSULTANT.  CHAIRMAN,  MEDIC...
Doctor is Answerable to (separately or jointly) <ul><li>Medical Council </li></ul><ul><li>Criminal Court </li></ul><ul><li...
Medical Negligence <ul><li>If a doctor  commits  any act which other reasonable doctor of his standard would not commit OR...
Non — Negligence <ul><li>Difference of opinion </li></ul><ul><li>Wrong diagnosis in spite of diligence </li></ul><ul><li>A...
Vicarious Liability <ul><li>Whatever is done by the staff </li></ul><ul><li>Whatever is done by partners, associates (locu...
Prevention of Clinical Medico legal Problems <ul><li>Attention  : Additional opinions </li></ul><ul><li>Behaviour  : Bill ...
B   Bills & Payments <ul><li>Professional bill do not come under the  purview of law </li></ul><ul><li>Prevent displeasure...
C   CONSENT <ul><li>Essentials of a valid consent  </li></ul><ul><li>Free consent- without coercion, undue influence, misr...
Consent <ul><li>Valid consent </li></ul><ul><ul><li>Competent person </li></ul></ul><ul><ul><li>Major / guardian </li></ul...
C   CONSENT <ul><li>Written consent  OR  Implied consent </li></ul><ul><li>Informed consent relevant information of illnes...
Consent <ul><li>Why doctor should feel shy of informing & taking written statement to that effect? </li></ul><ul><li>BOLDL...
C  CERTIFICATE- Care  while issuing  <ul><li>On Letter pad only-  Doctor’s Name, Qualification,Address and Registration no...
CERTIFICATE_Care while issuing- continued <ul><li>Identification mark of the patient  and/or The thumb impression </li></u...
Death Certificate <ul><li>NO FEES  </li></ul><ul><li>CONFIRM DEATH PERSONALLY </li></ul><ul><li>SUSPECED HOMICIDE  INFORM...
Medical fitness “will document” <ul><li>Issue to a known person only , Otherwise confirm identification </li></ul><ul><li>...
D   MEDICALDOCUMENTS <ul><li>It is your  FRIEND  OR  ENEMY   </li></ul><ul><li>Aim-  Patient’s monitoring </li></ul><ul><l...
D   MEDICALDOCUMENTS <ul><li>Should be  -- Clean- Avoid overwriting.  </li></ul><ul><li>Correct and  Comprehensive.  </li>...
MEDICAL DOCUMENTS <ul><li>Preservation  </li></ul><ul><li>M.L.C. s  -----  for ever  ( 30 years )  Administrative papers  ...
D   MEDICAL DOCUMENTS <ul><li>Whose Property  -  </li></ul><ul><li>Hospital has right over papers  but </li></ul><ul><li>S...
MEDICAL DOCUMENTS <ul><li>Patient has a right to demand it  at a  reasonable fees and in reasonable time.  </li></ul><ul><...
MEDICAL DOCUMENTS - Discharge card <ul><li>Short history, clinical notes, summary of  </li></ul><ul><li>operation and/or t...
MEDICAL   DOCUMENTS - Prescription <ul><li>As far as possible-  Neat ,Good hand writing  </li></ul><ul><li>Drugs  in  CAPI...
MEDICAL DOCUMENTS-Referral Notes and Transfer notes <ul><li>Carbon Copy should be kept. </li></ul><ul><li>Put Date and tim...
Any -- ?????????? Earnestly Invited from the   audience
THANK YOU   <ul><ul><ul><ul><ul><li>*********************************** </li></ul></ul></ul></ul></ul>
 
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107 medical documentsn-litigations.(daman)

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107 medical documentsn-litigations.(daman)

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

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