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2008| October | Volume 1 | Issue 10
Online since
November 26, 2008
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MEDICOLEGAL REPORT
Treatment based on provisional diagnosis in emergencies
October 2008, 1(10):147-148
In case of emergencies, you may ignore a 'suspicion' until it is 'confirmed' by appropriate investigations and proceed to treat the patient accordingly. But duly record - the 'suspicion', investigations advised and the reason for ignoring the 'suspicion'.
Advising appropriate investigations at the earliest to rule out 'suspicions' is mandatory.
Investigations that have been advised must be justified in medicine and only in the interest of the patient.
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Filling of consent form - One person, one sitting, one pen
October 2008, 1(10):138-139
Consent form must be filled by one doctor/nurse, in one sitting, if possible without changing the pen though counseling the patient may take more than one sitting.
In consent form, carefully make entries at the appropriate spaces. Entries made at the wrong place raise suspicion.
In case where alternative procedures have already been contemplated, it is advisable to clearly specify each of these procedures in the consent form.
Specific consent for each and every type of anesthesia that is anticipated must be taken.
Hospitals and Nursing Homes must politely refuse anyone, even another qualified doctor, from interfering. (In the instant case, the patient's son was a qualified doctor. It seems his insistence to transfuse blood without cross-matching was refused by the hospital staff and this action was upheld by the court.)
Only a qualified blood bank technician must do cross-matching and certify compatibility of blood.
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Presumptive therapy for malaria in high grade fever
October 2008, 1(10):140-141
As per the NMEP guideline, starting presumptive therapy for malaria with chloroquine is a thumb rule in the management of high fever in India.
On provisional diagnosis, appropriate treatment can be started without waiting for the final diagnosis.
Presumptive therapy is permissible on a case-to-case basis.
Courts recognize and accept that for some ailments, there are no medicines and treatment is generally symptomatic.
Drugs, especially the ones required in emergencies, must be duly stocked in hospitals and nursing homes.
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Unjustified delay in referring a patient to a higher specialty
October 2008, 1(10):151-152
Unjustified delay in referring a patient to a higher specialty is negligence per se.
Postoperative advice and precautions must be promptly written and explained to patients. In case the same has not been followed and/or any resultant complication is noted, duly record these in the patient's medical record.
In case of any abnormal finding in the investigations or clinical examination of the patient, appropriate precautionary or curative treatment must be started immediately.
Prescriptions must have the date and time, the history and the condition of the patient, diagnosis (provisional/final), treatment, directions, and precautions.
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Nonavailability of a drug/equipment/treatment in India
October 2008, 1(10):142-143
Drugs and treatment protocols acceptable to the medical world but not easily available in India can be avoided. It is advisable to record this reason in the patient's medical records. (In the instant case, nonavailability of bubble gas in India when surgery was performed was accepted as a good defense by the court.)
Whenever the patient disagrees or seeks further time to consider an option, duly record it and take signature of the patient.
At times, there are requests from the patients to give false Medical Certificates (especially Disability Certificate) to help the patient. Giving such Certificates is not only professional misconduct but the Certificate can be used later to contradict you in a court of law.
Be sure that your line of treatment is in consonance with the accepted medical practice prevalent at the time of treatment.
Drugs and treatment protocols that are still in experimental stages must be avoided.
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Discharge/transfer summary of a patient with procedure related or iatrogenic complications
October 2008, 1(10):149-150
In case of a complication, mistake, or mishap during the course of treatment, a transfer summary or a discharge summary must be carefully prepared by the consulting doctor. It is necessary to briefly record the reasons for taking that particular course of treatment, the resulting complication/s, post-complication treatment, and reasons for transfer/discharge.
Procedures which have an element of risk must always be carried out by the consulting doctor and should not be assigned to junior doctors or nurses.
A criminal case will not bar a consumer court from entertaining the same case for compensation.
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Public advertisement of medical services
October 2008, 1(10):144-144
Before inserting a public advertisement about your professional services, be sure that you can deliver what you are promising.
Packages/estimates/quotes must clearly state what is excluded and what is included.
Not discharging a patient for nonpayment of charges is clearly forbidden.
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Treatment by 'remote-control'
October 2008, 1(10):145-146
The consultant under whom the patient is admitted, especially emergency patients, must physically examine the patient at the earliest.
If for some reasons the consultant is unable to attend patient within reasonable time, another qualified consultant must be requested to attend an emergency patient.
In case of emergency and inability to reach the patient, consultants can give directions to junior doctors over telephone. In such cases, it must be specifically recorded that advice by the consultant has been given on telephone as also the reason for delay in examining of the patient by the consultant. But at the first opportunity, consultants must reach and examine the patient and this fact also must be duly recorded.
In case of long leave or physical inability, appropriate instructions must be given to hospitals not to admit patient in the consultant's name.
Ensure that investigations of IPD patients are carried out promptly.
All medical records must have signatures of attending doctors/consultants at the appropriate place.
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Decision to perform a surgery/intervention/procedure
October 2008, 1(10):153-153
Surgery/Interventions must be justified and solely in the interest of the patient.
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