Medical Law Cases - For Doctors

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The bed-chart/bed-head-ticket is the most important, contemporaneous medical record having best evidentiary value in a court. It is a part of the medical records of an IPD patient. Hence, it must be maintained and updated regularly and preserved carefully after the patient is discharged.
Contraindications must always be taken into account before prescribing any medicine. If any contraindicated drug is advised, it is imperative to briefly record reasons for doing so.
Sticking to the standard dosage of a drug may be negligence in a given case. Doses must be modified with reference to the particular patient and his or her condition at the time of prescribing the dose.
Delay in starting the treatment, especially, in emergency patients is negligence per se.
The time when the patient is first checked must be duly recorded. Thereafter, entries must be serially made in the patient's medical records at stipulated intervals.
At the time of referring a patient, it is incumbent to properly check and record all vital parameters.
There must always be a reasonable justification for adopting a particular course of treatment.
In case of hospitals that provide both free and paid treatments, even patients who are treated absolutely free of cost can get relief from a Consumers' Court.
In case an employee doctor of the hospital is negligent, both the negligent doctor as well as the hospital have to pay compensation.

In cases where some further investigation is advised to confirm a diagnosis, it is advisable to refer and record the initial diagnosis as a 'provisional diagnosis'. (In the instant case, the cardiologist (OP 2) would have been legally more comfortable if he had termed his diagnosis of sinus node dysfunction as a provisional diagnosis in the absence of a 2D Echo report which was advised by him but not done by the patient).
Greater care must be taken in revising an earlier diagnosis. It is advisable to briefly record the reason/s for revising a diagnosis in the patient's medical records.
Hospital records must be kept safe and secure for a period of three years. Courts acknowledge their correctness in the absence of any evidence to the contrary.
Patient, especially serious ones, who seek premature discharge must be made to sign a 'Discharge against Medical Advice' form and appropriate entries must be made in the medical records also.
Patients' refusal to conduct any investigation that is advised, must be promptly recorded.

In a fit and proper case, postponing investigations and treating a patient symptomatically, especially in the initial phase of treatment, is not negligence.
Proper protocols must be developed and followed by hospitals and nursing homes, whereby investigations when advised by consultants must be done at the earliest in emergencies, efforts must be made to procure reports quickly, the consultants must be informed about the results of the investigation at once on receiving such reports, and any direction(s) given by consultants must be carried out forthwith.
ICU must have experienced and duly qualified staff.

Drugs for which administration of a sensitivity test or a test dose is mandatory, must not be administered without conducting the prescribed test. In the case of such drugs, it is very important to record in the patient's medical records that the requisite test dose has been given and that there has been no adverse reaction even after a lapse of the prescribed period.
If any adverse reaction occurs on administering a drug in spite of the test dose, prompt remedial measures must be taken and duly recorded.

In case any mistake or mishap is observed during treatment, promptly inform the patient and take remedial steps. If necessary, the patient must be immediately referred to another facility for appropriate treatment. Record both, the fact that you have informed the patient about the mistake or mishap, and the remedial steps taken.
Postoperative care and precautions must be specifically advised wherever required and duly recorded. In case the patient fails to follow the same, specifically record the fact and the resulting symptoms or problems, if any.
In case the patient insists on being referred to another hospital/doctor, duly record the fact that the referral has been done on the patient's request.

In law, medical records are sufficient to prove or disprove negligence. They have more evidentiary value over expert witnesses.
Requisite preoperative exercise must be done and the same must be duly recorded.
Reports of presurgery investigations are a part of the patient's medical records and must be carefully preserved.
If any surgery/procedure has to be performed in haste for bonafide reason/s, the reason/s must be specifically and duly recorded.
Do not perform a surgery/procedure without performing requisite preoperative exercise even on the patient's request. A patient's request is not a valid defence for skipping any requisite preoperative exercise and the responsibility thereof, lies squarely with the doctor.
In case of negligence, both the doctor and hospital will be liable for paying compensation unless there is an agreement to the contrary between the doctor, hospital, and the patient.

Postoperative care is as important as the surgery/procedure and includes regular monitoring of the patient and giving appropriate treatment as per accepted medical practices.
Once a patient is admitted or operated, it is the duty of the consulting doctor/surgeon to attend to the patient during emergencies.
In case of elective surgeries/procedures, if it is anticipated that providing postoperative care to the patient is not possible, then the said fact must be disclosed to the patient at the time of taking consent for the surgery/procedure and must be duly recorded. If postoperative care is to be managed by another consultant, the consent of the patient must be taken for the same in advance and duly recorded.
In case of an unexpected emergency where giving postoperative care to the patient is not possible, alternative arrangements must be made before leaving the patient. The reasons for inability to provide postoperative care must be briefly recorded by the consultant in the medical records of the patient.

In procedures or treatments where relapse is common, it is advisable to explain the said fact to the patient and duly record it in the consent form.
Mandatory investigations must be advised to confirm diagnosis, especially before starting sensitive drugs.
The patient must be duly informed about the side effects of the prescribed drugs and this fact must be appropriately recorded.
In the case of certain sensitive drugs or drugs having serious side effects, it is absolutely necessary to regularly monitor for such side effects and this continuous monitoring must be appropriately recorded.