An Unsigned Medical Record has no legal validity- National Commission

An Unsigned Medical Record has no legal validity.

(Medicos, you must at least read point No.5 herein below)

The requisite case pertains to that of Medi. Supri. Loaknayak Jaiprakash Narayan Hospital & Ors. V/s. K.M. Santosh. F.A. No. 244/2008, decided on 14/03/2016.

Case of the Complainant :

1. The 11 year old Complainant was admitted in the Hospital with the complaint of Headache. After numerous trials and tests, no diagnosis could be made. But on the contrary, due to wrong medication, she lost her eyesight and to add in her misfortune, her leg had to be amputated due to gangrene developed after wrong Injection. Thus she claimed a compensation of Rs.10 laks. (The little one took her last breath during the pendency of the appeal)

Case of Doctors :

1. Doctors & Hospitals denied all the allegations. She was admitted to the Hospital, as she was not happy with the treatment of earlier Hospital. Cause of headache was due to Neurocysticercosis (Cysticercal), which is a type of parasitic infection, with Encephalitis and blindness is a known complication of the disease. The patient could survive only because of the treatment.

Held by National Commission :

1. The Commission upheld the award of State Commission which saddled damages of Rs.5 lakhs upon Appellants .

2. There were serious lacunas on part of the Hospital in maintain records. MRI and CT Scan Reports were not filed on record. There was no mention of prior treatment in RML Hospital.

3. The Appellants failed to give any reasons for development Pseudomonas, a common hospital derived infection, as well as medication for this infection was also not mentioned.

4. Neither the case sheet nor the consent form was filed;

5. It is the primary responsibility of the hospital to maintain and produce patient records on demand by the patient or appropriate judicial bodies. However, it is the primary duty of the treating doctor to see that all the documents with regard to management are written properly and signed. An unsigned medical record has no legal validity. The patient or their legal heirs can ask for copies of the treatment records that have to be provided within 72 hours. The hospital can charge a reasonable amount for the administrative purposes including photocopying the documents. Failure to provide medical records to patients on proper demand will amount to deficiency in service and negligence. It is the duty of doctor or hospital to preserve, maintain the medical record for certain specified period under different laws like Limitation Act, Consumer Protection Act and the Directorate General of Health Service (DGHS), Prenatal Diagnostic Test Act, 1994, the Clinical Establishments (Registration and Regulation) Act, 2010 (Central Act No. 23 of 2010). These records are required in medical negligence, accident, insurance claims and in criminal cases also in the Labour Courts. Hon’ble Supreme Court and the National Consumer Commission in various judgments held the hospitals/doctors liable for medical negligence for non-production of medical record.

6. “Smart people learn from their mistakes. But the real sharp ones learn from the mistakes of others.” I have explained previously also about umpteen no of judgments which underlines the importance of keeping proper record & documentation and also the ill effects of failure. There is no escape for proper documentation. Always remember POOR RECORD IS POOR DEFENSE AND NO RECORD IS NO DEFENSE.

Thanks & Regards

Adv. Rohit Erande

Pune.