This document provides guidelines for doctors on safe clinical practices and handling medico-legal cases. It discusses the importance of thorough documentation, including maintaining proper patient records, obtaining informed consent, and notifying police in certain cases. Good record keeping is emphasized as the best defense against allegations of negligence. The roles and responsibilities of doctors and staff are also covered.

1. Medico- legal cases- “Safeguards a
Doctor Must Know”
By – Dr. Om Prakash Shah
Ex-HOD & Sr. Prof.
Department of Orthopedics
Dr S.N. Medical College Jodhpur(Rajasthan)
Prof. Department of Orthopaedics
Rohillkhand Medical College
Bareilly(U.P.)

2. Introduction
• It is quite apparent to all of us that medical
practice today has undergone a dramatic change
the mutual faith between doctors and patients
has been considerably eroded. court cases has
been increased against the doctors. so for safe
practice I am presenting some guidelines or
precaution to prevent and if occur handle the
medico legal of cases(consumer cases), Material
- We should consider the following guidelines for
safe clinical practice.

3. Importance of Record Keeping and
Documentation of Patient Care.
• This is most important but poorly implemented in our country.
• It needs great improvement and willingness to change current
practice.
• In western countries private practioner employ secretaries for
maintaining record.
• But in our country most consultant do not want to spend money for
record keeping and doing restaurant type practice (i.e. People
enter, service is provided, payment is received- end of matter).
• Until they face a medico legal problem doctors do not realize the
importance.
• Older days has gone when the doctor was a solo practioner who
treat everything, dispensed innocuous medicine and needed a very
few lab test.
•

4. • Good medical record keeping is extremely
critical to the delivery of good quality
medical care.
•
– Good medical records are your best defense
against allegation of negligence or medical mal
practice. For e.g. in court evidence.

5. Parts of medical record.
– But now patient records needs to document historical
information, i.e. current and previous medical problems, clinical
findings, diagnostic tests (pathology, radiology, sonography,
scan, MRI). Specialist consultation, treatment, operative
procedure, progress report, nurses’ report, final diagnosis,
discharge summary and follow up notes.
– It is very clear that treating a patient is teamwork of doctors,
nurses, technicians, paramedical staffs etc. Each one of them
has complete information about a patient from medical records
only and treat patient with confidence and safety. Follow up
patient can be treated by seeing old records.
– The following documents forms parts of medical records
• Opd record.
• IPD record(history, consent form, diagnostic record, referral &
prescription slip, patient case sheet showing daily progress notes,
operative notes).
• Medical Certificates
• Medico Legal reports.
• Dying declaration/deposition.
• Information to police.

6. • Good record
• Good record means it should be correct, clear,
comprehensive and chronological.
•
• Uses of Medical Records
• Medical Education
• Research of incidence, prevention & treatment of
diseases.
• Audit – Medical, Economic aspects
• Medical statistics
• It forms legal evidence in judicial proceedings.
• It forms base in life LIC claims, workmen compensation
etc.

7. Importance of Good Documentation
Record
– Always record time and date of examination (make it habit).
• Keep copies of all reports- in MLC absence of investigation
reports hampers an effective defense.
• The value of this is realized only in MLC or facing allegation
of malpractice & when you start preparing your defense &
discover that all reports are with the patient & you have to
rely on your memory or guess work.
• In follow-up when patient misplace their papers you have
nothing to treat.
• A mischievous patient (prompted by his advocate)
suppresses certain reports which might establish the fact
that you were not negligent.

8. Importance of Good Documentation
Record
• Always keep copy of discharge card
– It is the final report card of student
– It contains
• Date and time of admission
• Clinical Findings
• Past History
• Investigations
• Treatment Given
• Progress of the patient
• Date of operation( operative records)
• Complications
• Final Diagnosis
• Medicines to be taken
• Dietary instructions
• Follow up instructions
• Precautions and follow-up
• And most important, the discharge ticket is what the patient
carries home.

9. Importance of Good Documentation
Record
• Indoor Case Records- For court purpose whatever is not
documented in your notes, never happened regardless of whatever
you have actually done.
– Continuations Sheet must be numbered, have the name, registration
number, diagnosis, ward and bed number of the patient.
– Bed head ticket should be written in clear hand writing.
– Alterations as far as possible should not be erased, overwritten or
inked out. Advocates love alterations and create doubts in the mind
of the judge. It is better to cut the entry, sign it and write the correct
entry alongside.
– Abbreviations can cause confusion. For e.g. PID (Prolapse IV Disc or
pelvic inflammatory disease), SCOOR (something coming out of
rectum), POOF (Plenty of oral fluids).
•
– Consent should be taken in separate paper.
•
– On discharge of patient take receipt of documents handed over.

10. Importance of Good Documentation
Record
• OPD Records usually kept in private hospitals or corporate
hospitals equipped with computer. In MLC cases the absence of
OPD records hampers the defense of the case and we are at the
mercy of the patient to provide us the paper. Solution is to keep
two copies or computerized record.
•
• Proper history taking
– Performa showing no history of diabetes, hypertension,
asthma, any operation, accident etc.
– Accurate and systematic history taking will manage
health care system and privatization of Health Insurance.
Hence get smart make patient declaration Performa
routinely. It may save you a lot of botherance some day.

11. Consent
• Take consent even for minor procedure.
• Consent should always be in written. Avoid oral
consent.
• Take consent in patient own language. In MLC patient
advocate make a big issue and patient says that doctor
has given me a paper to sign at bottom over dotted line
and I don’t know what is written in the form.
• Consent should be informed to the patient. In US
without informed consent a doctor will be held liable
for violation of patients’ rights.
• Consent must be signed by the patient accept
in case of minor, unconscious or semi
conscious or mentally unstable patient

12. Consent
• In gradients of informed consents
– Patient understands his medical condition.
– Patient understands proper treatment or procedure.
– Patient understands alternative treatment.
– Patient understands risk/complications of proposed or alternative
treatment.
– Patient understands chances of success or failure of proposed
treatment.
– Patient knows the identity of surgeon.
– Disclose any risk of death or serious harm.
– Disclose peculiar risk with a specific treatment.
– Patient understands the theatre condition. The staff and its
efficiency.
– Patient understands the availabity of facilities in OT or Hospitals.
– Patient understands complications of particular procedure proposed
for his treatment.
•
• Denied consent should also be recorded. For e.g. you advice
investigations (CT, MRI) and patient refused.

13. Transferring the Patient
• Give the patient/relatives a few options to
shift the patient.
• Proper follow up should be made of patient.
• Always keep a copy of transferring notes and
investigation reports.
• Make note in your records, the needs to
transfer the patient.
•

14. Documentation and Medical Records
• Stationary –
– Writing “This report is not meant for medico legal purpose” or
similar quotes on the stationary used is of no help. Every
report, prescription, advises can be used in a court of law
against the doctor irrespective of such statement. This
statement creates unnecessary adverse inference in the court
against the doctor accused of medical negligence and hence
this practice should be stopped.
– Stationary especially letter pad must be carefully kept, if stolen
and fabricated documents prepared, they creates medical
negligence and legal problem.
•
• Writing:
– Avoid changing ink or pen mid way in writing medical records,
as this is projected as manipulation in court.
– Courts draw an adverse inference in case of overwriting,
deleting, putting whitener etc. It is advisable to encircle the
mistake then write the correct thing.

15. Legal Position in Treating Accident
Emergencies
• Merely not charging patient fees doesn’t give you immunity from being pr
oceeded under the consumer protection Act. (Only those hospitals where
free treatment is given to 100% patients even if normal registration fee is c
harged) are exempt from coming under purview of the Act. So please char
ge your profession fees, not charging fees do not mitigate your liability.
• A patient who promises to pay you (Though he may not have actually paid
you) also enjoys the status of a consumer. Even a patient who does not pa
y you has the rights of a consumer if other patients in the hospital are bein
g charged.
• It is well established that in a dire emergency or life threatening situation c
onsent of a patient or relative is not required. The attending doctor becom
es the guardian of the patient. Hence not having consent in such situation
is not considered a valid reason for not treating patient.
• As per SupremeCourt decision in the case of permanand katara Vs. Union
of India, The preservation of human life is of paramount importance. Henc
e an injured citizen brought for medical treatment should be instantaneou
sly given treatment to preserve life. Hence no doctor is expected to refuse
to treat a patient in an emergency.

16. Issuing Death Certificate:
• Issuing a death certificate for a patient brough
t dead, with no attendants and no personal kn
owledge of the cause of death, is a for potenti
al trouble.
• It is unwise to issue a DC in order to oblige the
relatives. Misplaced sympathy to save post–
hassles can backfire once in a way. And
just one such case is enough to cause you a lot
of trouble.

17. Intimating Police for Medico Legal Cas
es
• Cases of RTA, Assault and other injury cases, burns, poisoning etc. have to be infor
ming to the police as per law.
•
• Keep Following Points in Mind
• Emergency treatment should be given preference. However information to be don
e as early as possible. Unreasonable delay may call for explanations. Note the time
of intimation and when police came, note his Bella number. If you send written inti
mation then get an acknowledgement. It is not certain that police will not come pr
omptly but at least you have done your duty.
• Whenever police constable complete his formalities make sure that he signs and m
akes some notation in your case paper in token of having done needful. This is imp
ortant proof if police denied.
• In RTA always inform police for minor injuries also.
• The settlement between accused and victims should be done in front of police. If l
ater on dispute occur, police will harass you of not informing police at the time of i
njury.
• Suicide is a crime. Attempting suicide by organophospherus poisons or sleeping pill
s etc. must be informed to police in a reasonable time and not later when patients
condition becomes critical
• If the patient is saved then refer him to Psychiatrist to prevent further attempt as p
atient has suicidal tendency. If relatives are unwilling document this in case sheet.

18. Availability of Emergency Services
• If you stick Board on your nursing home “24 hr
s. Emergency services available” make sure thi
s is really the case. Otherwise it may create pr
oblem, if someone is not attended and suffer
damage.

19. STAFF LIABILITY
• As per the law, an employer is responsible for action of his employees
• It is the right; duty and responsibility of the employer supervise the employees.
• While selecting staff check their original certificates of qualification and experience
and keep their record. Always employ qualified staff although experience but
• Note following points...
– Discourteous or rude behavior by your staff members (nurse, 4th class,
receptionist, ward boy, sweeper etc) could be the root cause of your
allegations, otherwise sound management of the patient. The displeasure of
patient against your staff members can be easily directed towards you.
– Your staff represents you. Both credit as well as discredit of their performance
will go to you. Whereas a consultant doctor spends hardly a few minutes with
the patient, the staff who is with the patient round the clock can make all the
difference.
– An unhappy employee can cause you a lot of loss sometimes in the form of
medico legal problem.
– Good staff can prevent many problems (including medico legal problems).
Good staff should serve as the eyes and years of the physician. Any disturbing
behavior of the patient or its relatives should be reported to the doctors.
Invariably the staff rapport with the patient and know the innermost thought
of the patient. It is wise to take feedback from the staff and take action
accordingly. This will happen if you sensitize your staff to this particular
aspect.
– Instruct you’re not to act beyond the scope of their duties. This can create
sometimes unimaginative problems.

20. Handling Allegations of Patients
• Don’t ignore allegations of patients – whether
oral or written.
• Handle allegations with sympathy, intelligence,
tact and firmness.
• Take professional guidance before answering
anything in written.
• Make a police complaint in case of physical
threat.
• It may be advisable to take guidance from your
associates.

21. Surgery/Procedure/Intervention
• Anesthetist must be always involved where it is necessary.
• PAC – should be done one day before along with notes.
• Anesthetist should put his notes during surgical procedure and write post
operative instructions also.
• Postponing surgery on astrological region by doctor is not his defense. If
patient do not gives consent you withdraw the treatment with record.
• Complicated surgeries should be done by experienced and skilled doctor
of that procedure. If doctor of that specialty is not available on such day,
postpone the surgery.
• Always take high risk consent for surgery from patient with abnormal
vitals.
• Guess the complications of the surgery and make necessary preparations
for the same.
• The principal surgeon will be liable in court for any mistake committed by
any member of surgical team.
• Always record pre-intra and post operative notes especially complications.
• In case a procedure require multiple session, explain it to the patient with
dates.
• Elective surgery should be done only when patient is completely fit.

22. Surgery/Procedure/Intervention
• Surgeon is responsible for post operative care; if he goes on
leave manage other doctor of same caliber.
• Stopping surgery mid-way on safety ground is not
negligence, but it should be recorded and informed to the
patient.
• Leaving any gauge or equipment in the body is negligence.
• Specifically inform the patient in case any part or organ is
removed.
• Surgical complications if occurred must be informed with a
sense of urgency.
• Write post operative instructions.
• Post operative infections should be checked and recorded.
• In case of deviation from the advised surgery it is
mandatory to record the regions for any such change in the
operative notes.
•

23. Insurance Cover for Medico Legal
Liability
• Ideally safe practice thereby avoiding MLC is our motto. But it is wise to
protect from unhappening MLC by taking Professional Indemnity
Insurance.
• One should not practice even a single day without insurance. In USA it is
compulsory. Its importance is understood when a legal notice from a
patient come to you demanding huge money for compensation.
• Cost of insurance – Rs.2000 for 10 lakhs for one year.
• Coverage: It covers against legal liabilities from claims arising of bodily
injury or death of any patient caused or alleged to be caused by your error,
or negligence in professional service …
• Categories:
– Personal or individual
– Errors and omission policy – covers institution, nursing home or hospitals
along with its staff members.
– Precautions:
• Fill Form personally, carefully and truthfully. Do not hide the past fact. In omission
policy if staff is not qualified then write ‘No’ but fill ‘Trained’. They will take some more
premiums.
• Always preserve copy of policy.
• In the column AOY (Any One Year): AOO (Any One Occurrence) ratio always opt 1:1 ratio.
• Always check retro active dates. Renew policy without single day delay.
• Preserve your policy for several years.

24. Step To Step Guide to Deal with
Consumer Forum Notice
• As soon as you received a notice from forum, a variety of emotions
occurs like – hurt, shock, anger, humiliation, guilt, always fear and
often panic. At this time you need maximum support and guidance.
But the fear is imaginary and arise out of having to deal with a
situation which is unpleasant. What to do now...
• Note down the date on which you received the notice and forum
(District – 20Lakhs, State – 20 Lakhs to 1 Crore, or National - above
1 Crore), because you have to reply within 30 days and also note
the date of reply.
• A copy of complaint of the patient usually accompanying the notice.
Read it carefully, what are the allegations made against you? If
complaint copy is not attached, inform the forum.
• The reply should be drafted carefully after consultation with your
association and with an advocate. Also appoint an advocate.
• Now make the summary of events – write in detail the occurrence
of the whole story from the time you first met the patient till the
present time.

25. Step To Step Guide to Deal with
Consumer Forum Notice
• Reply of the allegations – Generally complaints of patient is
prepared by an advocate and is in the form of numbered paragraph.
Read thoroughly the complaint and allegations and prepare your
own reply or medical explanation.
• Send a copy of the following to your advocate:
– Copy of complaints
– Summary of events
– Reply of allegations
• Now collect medical literature related to your which cause the
conflict from text book, journals or internet and send a copy to your
advocate.
• Take expert opinion from senior consultant in the form of affidavit.
• Your advocate now finally draft the reply which should be
submitted to the forum along with necessary documents within 30
days. You can demand a 15 days extension also.
• Sometimes patient makes allegations against more than one person
i.e. surgeon, anesthetist and hospital, and it may happen that
instead of replying to the allegations complainant start opposing

26. Step To Step Guide to Deal with
Consumer Forum Notice
• Summary : If you are having professional indemnity policy
in the insurance following actions are to be taken –
– Inform insurance company through your agent and medico
legal cell (if any) about the receipt of the notice from a
consumer a forum (send notice, complaint and photo copy of
your policy).
– Mention the name of advocate who will handle your case.
– Ask your claim to be registered and to be notified the claim
number.
– Keep informing the progress of case to insurance company.
• A word of caution – Do not neglect the notice of consumer forum
once the reply has been filed keep continuously in touch with further
developments. In a few cases lack of attention of the concerned
doctor have resulted in adverse judgment.

27. Efficient Dealing with the Patient
• The key to good patient rapport is good communication.
The key to good patient communication is listening and
because of good doctor – patient relationship medico legal
cases can be avoided.
• If patient questions are not answered – it becomes
anxiety, resulting into aggration giving anger and this anger
will call advocates, social workers, media persons etc. The
main importance during patient conversations i.e. (listening
and replying i.e. talking). 80% - 90% role is of your body
language.
• God has given two ears and one mouth i.e. hear twice
than speak.

28. CONSENT FORM
• I (name of patient) S/O, D/O, W/O, M/O Registration no. –
• Age - … Sex - …. residing at - …………………………….. of my free will
give my consent for ................................................. (Name/Type of
operation/Procedure ) under…........................ (Type of Anesthesia)
• The risk involved in surgeryprocedure and anesthesia have been
explained to me and I accept the same. I understand that the
procedure is being done for my benefit. I also understand that the
operation/procedure/anesthesia of drug administered may cause
some unintended short term or long term complications of
disabilities which I accept. I leave extent of surgery to the discretion
of the operating surgeon.
• Sign of Patient
• No guarantee of my cure has been given to me. About the
result of anesthesia or surgery.
•
• Witness sign - Sign of patient ……………….