NMC Advice: Doctors should Carefully Document Patient's Case History, Examination Findings

New Delhi: Observing that proper documentation is the best defence of a treating physician in medical negligence cases, the National Medical Commission (NMC) has advised the doctors to ensure that the case history of a patient or the examination findings are carefully documented.

The Apex Medical Commission further emphasised the fact that there should not be a mismatch between the clinical notes made by the treating physician and the progress notes made by the attending nurse.

These observations were made by the Commission in its recently released E-Book "Professional Conduct Review- Lessons from Case Archives", which was released by the Ethics and Medical Registration Board (EMRB) of NMC on October 05, 2023.

Among the nine cases that have been discussed by NMC in this book, one of the cases relates to the treatment of a young male patient at a private hospital.

The patient was taken to the emergency department of the private hospital (X) with fever, abdominal pain and two episodes of vomiting for two days. As the patient had hypotension and thrombocytopenia, a provisional diagnosis of dengue fever was made and symptomatic treatment was initiated. Due to the nonavailability of the ICU beds at Hospital X, the patient was shifted to another private hospital (Y) on the same day for further management.

Consequently, the patient was admitted to the ICU of Hospital Y under a Pulmonologist. He continued to receive treatment for Dengue fever under a team of pulmonologists and gastroenterologists. The patient was referred to a Gastroenterology consultation for abdominal pain and he was managed conservatively with antibiotics, antipyretics, and IV fluids.

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A series of investigations were done including USG which indicated cystitis & Dengue NS1 was negative. The patient was accepting a soft bland diet and passing flatus during the stay. The condition of the patient improved and he was discharged after four days. The discharge summary mentioned acute febrile illness or acute gastritis with dehydration, UTI, or Cystitis.

However, within 36 hours of discharge, he had a relapse of abdominal pain and he was rushed to another private hospital (Z). At this hospital, a diagnosis of volvulus, small intestine obstruction & gangrene was made necessitating emergency laparotomy and bowel resection.

An emergency laparotomy was done with resection of the small bowel and anastomosis. Consequently, the patient's condition improved, and he was discharged after six days.

Following this, the patient's father filed a plea before the erstwhile Medical Council of India (MCI) alleging medical negligence against the treating doctors i.e. two pulmonologists and one gastroenterologist of the hospital (Y). The complaint was made for wrong diagnosis leading to delay in treatment.

The patient's father, who is a doctor, alleged that the two pulmonologists and a gastroenterologist at the hospital Y failed to diagnose and treat early intestinal obstruction, which led to lifethreatening small bowel gangrene. This resulted in emergency laparotomy, resection & anastomosis of the small bowel.

He also alleged that the patient was admitted/treated in the wrong specialty (pulmonology) and therefore the pulmonologist missed the past history of abdominal surgery and failed to observe the abdominal scar. This led to the wrong diagnosis and delay in treatment.

The plea by the complainant was forwarded to the State Medical Council by the Indian Medical Council. The accused doctors submitted an internal inquiry report of the hospital to the State Medical Council stating that the diagnosis of acute debrile illness and no deficiency in service to the patient.

However, since the State Medical Council failed to conclude the matter within the stipulated time of six months, the NMC Ethics Board took over the case and directed the petitioner and the doctors from Hospital Y to appear before the committee.

While considering the matter, EMRB observed that qualified doctors treated the patient at the hospital (Y) and the patient was fit for discharge making the diagnosis of treating physicians justifiable.

The Ethics Board further observed that even if it was an intestinal obstruction, it may have been partial and not persistent, therefore justifying the conservative treatment.

Further, the NMC Board noted that even the complainant, who himself was a senior doctor, had no complaints at the time of discharge. The Commission opined that previous operating history/abdominal scar does not itself make the diagnosis of intentional obstruction.

"Volvulus of the small intestine is a rare acute condition and can result in small bowel gangrene. Worsening of the symptoms occurred after discharge from the hospital Y. Such instances of evolving dynamic diseases leading to errors in diagnosis do not necessarily justify the case of medical negligence. The doctors in the present case had provided a reasonable degree of care," observed the NMC Ethics Board as it decided to exonerate the doctors of the Hospital Y.

While discussing the matter, the Apex Medical Commission mentioned in its E-Book that clinical diagnosis and the human body are very complex and also observed that two different diseases can occur in the same patient in a short span of time.

"In clinical medicine, it is a practice as far as possible to try and explain all symptomology through a single disease etiology. This may lead to wrong diagnosis and delay in treatment. In the realm of diagnosis and treatment, there is scope for genuine difference of opinion and one professional doctor is not negligent merely because his conclusion differs from that of another medical professional," observed the Commission.

Further, the Commission emphasised on the need for proper documentation of the case history and examination findings. "History/examination findings should be documented meticulously," it mentioned.

NMC referred to the fact that one of the allegations in this specific case was a history of previous abdominal surgery and the inspection finding of the abdominal scar was not documented by the treating physicians at hospital Y.

At this outset, the Commission opined, "Proper documentation is the best defence of a treating physician in the medical negligence cases and in the court of law. There should not be a mismatch between the physician's clinical notes and the nurse's progress notes."

Further, the Commission also explained the importance of proper communication between the doctors and the patients and noted, "The condition of the patient should be briefed to the relatives/attendants of the patient regularly. Proper communication may avoid misunderstandings among relatives/attendants of the patient and lead to trust in the doctorpatient relationship. Even though the petitioner is a doctor in this case, he alleges that the condition of the patient was not properly explained."

Addressing the issue of medical negligence, the Commission noted, "Negligence is the breach of a duty exercised by omission to do something which a reasonable man, guided by those considerations which ordinarily regulate the conduct of human affairs, would do, or doing something which a prudent and reasonable man would not do. The medical professional is expected to bring a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. Neither the very highest nor a very low degree of care and competence judged in the light of the particular circumstances of each case is what the law requires. A medical practitioner would be liable only when his conduct falls below that of the standards of a reasonably competent practitioner in his field."

Medical Dialogues had earlier reported that altogether nine (9) case archives were discussed in Volume I of the NMC's E-book. In respect of each and every case, NMC discussed different topics including Communication Between Doctor and Patient's Relatives, Allegations of Wrong Diagnosis Leading to Delay in Treatment, Specialty Practice-Without Adequate Qualification/Training etc.

For each of the cases, the book elaborates on different aspects such as the keywords, context/category, abstract, summary of the case, discussion, decision of State Medical Councils or NMC Ethics Board, lessons learned from the case, take-home message, etc.

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