It is wise to remember that “Poor medical records mean poor defense, no records mean no defense”, hence liable for medical negligence. ”
These are the opening words of National Commission which held the Orthopedic Surgeon liable for medical Negligence for damages of around Rs. 4 lacks in its recent order dated 13/10/2015 in the case of Venkati Vattamwar V/s. Dr. Prakash Bhandari.
The factual matrix in nutshell may be read as under :
The Complainant who won the case in District forum, but lost the same in State Forum, was admitted in the Opponent’s Orthopedic Hospital due to motorcycle accident and was diagnosed with a small fracture in right leg !! During the stay in hospital, there was no sign of improvement and the patient in spite of 2 operations and a plastic surgery, which was performed just 1 day before discharge. As there was no improvement, the Patient was advised to go to Sancheti Hospital, Pune, 450 km away from Nanded !!. The Complainant contended that the timely reference could have saved his leg from being imputed.. The Doctors denied the allegations and contended that the patient on his own shifted to Pune and during the 10 hrs. long journey, the injury of leg might have worsened. it was also submitted that the treatment was proper, but because of skin necrosis on 5th day, the patient developed skin loss about 2½ inch on anteromedial aspect of the leg and The Toe movements were absent because of neurological deficit.
The Commission while allowing the appeal observed that there was no medical record produced by the Opponent, but Dr. Sancheti who gave opinion that the patient must have developed compartment syndrome due to soft tissue injury and venous thrombosis leading to edema and further opined that the opponent took all the proper care, stated that he is giving evidence on the basis of Evidence !!
The National Commission also turned down the suggestion of Opponent Doctor who suggested cross leg flap for necrosis of skin, about 2 ½ X 2 inch and observed that a simple dressing or a small graft would have been helpful and further observed that the need for cross leg flap, itself indicates that, there was extensive necrosis of the skin, on which the Dr. Sancheti did not give any opinion. The Commission observed that the opponent has failed to prove his bonafide for want of medical Records and hence directed the doctor to pay the patient the demanded amount !!!!
The Commission held “NEGLIGENCE” a relative term, is an omission to do something, which a reasonable and prudent person guided by the considerations, which ordinarily regulate human affairs would do or doing something, which a prudent and reasonable person guided by similar considerations would not do. It is difficult to state with precision, any mathematically exact formula, by which negligence or lack of it can be infallibly measured, in a given case. Whether, there exists negligence per se or the course of conduct amounts to negligence would normally depend upon the attending and surrounding facts and circumstances which have to be taken into consideration by the Court. In a given case, even not doing what one was ought to do, can constitute negligence.
This was summarised in the said case with the quote from the hon’ble court saying
Medical record maintenance is an important aspect of the management of a patient. It is important for the doctors and hospitals to properly maintain the records of patients. It will help the doctor to prove that the treatment was carried out properly, which will help in analyzing the treatment results, and to plan treatment protocols. It is wise to remember that “Poor records mean poor defense, no records mean, no defense”.
I have in my earlier Articles for several times written that Doctors whether they like it or not, whether the patient is regular or not, should maintain proper Medical Records.. Even when you give prescriptions, please make 1 +1 copy of it and fill up all the details and info you can, those extra 5 -10 mintues will save your 5-10 lacks rupees !!!
Adv. Rohit Erande
You can read the judgement here