Importance of Record Keeping

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-: Importance of Record Keeping :-

| Investigations | Referal to Specialist | Anticipating Complications |
| Insurance | Procedure before Consumer forum | Doctor as Consumer |
| Model information sheet |

   
 

If any legal problem arises than properly maintained records are of utmost importance. They are proof of what one has done actually for his patient. Record includes.

a.) Informed consent.

b.) Chronological order of progress of disease and treatment, investigations, opinions, X-rays etc.

c.)  Details of procedure or surgery or anesthesia given.

d.) Record of investigations be it radiological, pathological or reports of CAT or MRI or any other opinion of specialist or consultant.

e.) Record includes record of refusal of treatment or investigation or surgery.

f.)  Records of adult patients are maintained for 3 years and children for 21 years. (3+18 years).

 

 

 

 

IMPORTANCE  OF  INVESTIGATIONS / X-rays/ MRI/ CAT SCAN/ SONOGRAPY

Importance of investigations: In modern time a proof of establishing diagnosis is most essential.  A documentation of such diagnosis can be done by well-planned out investigations. One must avoid unnecessary investigations. One must prefer non-invasive investigation or invasive one. Routine investigation to get basic knowledge about patient’s condition is essential. Legally speaking investigations speaks and vouches for correct diagnosis and indication for treatment and surgery performed by doctor.Few rules for asking investigations are in following fruitful and beneficial manner:  

1.    Define the diagnostic dilemma or differential diagnosis properly.

2.    Ask yourself that after getting the results of investigation you will narrow down in your diagnostic dilemma or
       differential diagnosis. 

3.    Avoid asking special investigations routinely. Only Basic investigations like: Blood count. Stool, urine, etc. could be under taken routinely. Diseases caused by bacteria should be cultured 

4.    Is precise diagnosis must before proceeding for management and treatment or gross diagnosis will be sufficient.

5.   What difference it will make if particular investigation is not done will it harm patient?

6.    What possible harms can be done to patient while undertaking particular investigation. Can it cause death?

7.    Will cost of investigation burden patient more than it will benefit him ?

8.    Is investigation required urgently or can it be postponed ?

9.    Is there any way to reach to diagnosis e.g. follow-up  etc. which could avoid investigation.

10. All the circumstances related to in terms of its need, urgency, cost, benefit should be told to patient.

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IMPORTANCE OF REFERAL TO SPECIALIST

If time and condition of patient permits one should obtain expert opinion in ” out of the routine” cases and all serious patients. Importance of seeking medical history and information from relatives and patients as described and annexed to consent from. Why reference to specialist is needed and when?

 

1.    For confirmation of the diagnosis and management plan of a particular patient.

2.    All serious patient should get benefit of specialist so as to avoid “missed chance” situation later on when
      patient becomes worse.

3.    All unusual cases must be referred to specialist.

4.    More than one persons opinion, if opinion concurs, has better value in the law courts in case of any legal
       problem, if any, arises later on.

 

5.    References are made to specialist if any procedure can not done with out his help. Special skill is needed for
       the procedure which only specialist can offer. eg. Venesection, Lumber puncture

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ANTICIPATING COMPLICATIONS

KNOWN AND UNKNOWN COMPLICATIONS OF DISEASE, INVESTIGATIONS AND PROCEDURE:  One is expected to take reasonable standard care for known complication and must explain patient and relatives in detail and to their satisfaction all these complications. Unknown complication arise out of a situation must be tackled in goodfaith, sometimes with adventure to save life. One should do utmost to save life and let it be known and felt by patient and relatives. Few rules to remember while tackling complications:

• Calculate drug does properly as per kilo of body weight particularly for drug, which have depressant action on respiration and heart. Give these drugs after proper dilutions. Give drugs very slowly if needed to be given intravenously so as to avoid any unknown complications.

• Anticipate known complications and be prepared to tackle them in time and effectively.

  Keep ready life support system.

• Life threatening unknown complication should be tackled with out fear of ” what people will think ” Patients life is of supreme importance and one can not even wait for consent in unusual life threatening situations.

  (Unforseen complication teaches a lesson to each doctor and may help in advancing medical treatment).

• Law courts are not going to hold you responsible for any untoward incident or even death as a sequel of  any unknown complication or any error of judgement or misadventure. What is required of a doctor is standard, reasonable medical care of an average medical professional.

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INSURANCE

Insurance and Doctors:

Insurance is a special contract where payment by insurer is contingent on liability arising out of contingent loss. Insured pays consideration in terms of premium to insurer. On same principles of insurance doctor’s indemnity policy is based.

• Doctors indemnity policy:

  Any liability arises out of civil litigation insurance company will pay for the insured amount (indemnity covered for). Limit of insured amount per case during the year or all cases during the year should be same. Minimum premium is for physician and is double for surgeon, triple for plastic surgeon. There are number of exclusion clauses which must be studied before taking indemnity cover from insurance companies. Generally it is RS 1000/= for RS. 10,00,000/+ of insurance for physicians.

• Doctors composite package insurance: It covers building, contents of dispensary or hospital and consulting room including furniture, fixture, fittings, stocks of medicines, medical instruments and kits and electronics items, neon sign board and doctors professional indemnity etc. Same contents can be covered for burglary, housebreaking and theft, finality guarantee for cashier, compounder or other authorized employees. Limit for fidelity is 20,000/= also covers money lost in transit.

• Other insurances:
  

  a.) Mediclaim: Covers disease, which needs hospitalization, all expenses during hospital stay.
  b.) Personal accident policy: covers any type of accidental injuries or death anywhere in world and provides for weekly compensation for the loss of income incurred due to accident.

  
  c.)  Motor car insurance policy

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PROCEDURE BEFORE CONSUMER FORUM

• Any patient having claims less than/equal to five lakh rupees can approach district consumer forum for        redressal which is situated in each district.

• A patient with claim more then RS. 5 lakh but less then /equal to RS. 20 lakh  approaches state commission or prefers an appeal against in 30 days of district forum’s order.

  A doctor can also appeal to state forum against forum’s order with in 30 days.

• Patient having claims of more than 20 lakh may approach national commission are appeal with in 30 days from the order state forum.

• Doctors receive copy of complaint filed by patient from consumer forum and have to file written statement return reply with in 30 days of receipt to commission.

  This may be extended upto 15 more days.

• Complainant is asked to adduce evidence on affidavit so also the opposite party.

• Most of the time simple clean cut deficiency of services is tried before consumer forum and complaints involving complicated issue of law and evidence are referred to civil court.

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DOCTORS AS CONSUMERS

 

1.    A Doctor is a consumer if he buys goods and services for his own consumption or use.

2.    A Doctor is consumer as far as following services are concerned:

       a]  Insurance claims including doctor’s indemnity and doctor’s composite policy and mediclaim.

       b]  Banking services.

       c]  Postal and telecommunication services.

       d]  Electricity services.

       e]  A Doctor is a consumer for the purpose of the equipment he buys for use for his patients. He can also
           approach Monopolistic and restrictive trade practices commission, MRTP House, Shahjahan Road, New
           Dehli-110029.  

      f] So in conclusion whatever doctor buys for the benefit of his patients he can now claim to be consumer
           if any defect in goods or deficiency in service  is found.

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INFORMATION  FROM  PATIENT  AND  MEDICAL  HISTORY      

ONE CAN CHOOSE INFORMATION FROM FOLLOWING MODEL INFORMATION SHEET OR MODIFY I_______________________________________________________________ Born on________________________________ female, Married/single/divorced. R/o________________________________________________________ ____________________________________________________________ Occupation _________________________________________________________ CANCEL “NO” IF “YES” THEN GIVE DETAILS: WRITE N.A. FOR NOT APPLICABLE  

1.    Do you have diabetes? NO/___________ 

2.    Do you have blood pressure (Hypertension) No/_____________ 

3.    Do you have heart trouble? NO?_______________ 

4.    Do you have lung trouble. (asthma etc.)? NO/_________________ 

5.    Did you have abnormal bleeding after extraction/surgery/injury? NO/____________

  6.    Did you have allergy/reaction to any medicine /injection (e.g. penicillin, sulfa etc.)NO/_________ 

7.    Are you taking any drug or medicine? NO/_______________ 

8.    Did you have serious illnesses or operation? No/_______________ 

9.    Did you have fits/fainting attacks/giddiness? No/_____________ 

10. Did you have jaundice? NO/______________  

11. Are you HIV positive? No/_______________  

12. Are you Australia Antigen positive? No/______________  

13. Do you have rheumatic disease? NO/____________  

14. Do you suffer from hay fever, eczema or any other Allergy? NO/___________  

15. Are you an expectant mother/breast feeding? NO/____________  

16. Is there any matter you wish to discuss? NO/__________  

17. Number of deliveries_____________  

18. Nature of deliveries Normal/forceps/caesarean/premature/stillbirth/miscarriage/abortion-__________
      Date of last Menstrual period:   /   /  

19. Menstrual period: Regular/irregular/painful/scanty/too much_____________ 

20. History of birth defects in any children: No/____________  

21. Did you have swelling of feet/swelling eyelid : NO/______________  

22. Did you have Eclampsia/vesicular mole/placenta praevia/twins/triples/multiple pregnancy:
      NO/________________  

23. Are you suffering from anaemia : No/_____________  

24. Do you have ulcer/acidity : NO/__________  

25. _____________________________________________ I hereby declare that I have not concealed and
     fully disclosed all material facts regarding the status of my health relevant to medical /SURGICAL/MEDICAL
     treatment.  

SAMPLE OF IDEAL CONSENT FORM: ONE CAN CHANGE TO SUIT INDIVIDUAL DOCTORS REQUIRMENT                                                                                    
                                                                                                                            Date ../../  



I hereby employ Dr.____________________________ for the personal services for my  MEDICAL/SURGICAL  treatment. I____________________________________________________ R/o _________________________________________________       _________________________________________________ I hereby declare that I am more than 18 years of age. I hereby consent to the performance of SURGICAL /MEDICAL  treatment upon myself or my____________________________________________________ Daughter/wife/ward/niece/neighbour or any other _________________________ Such treatment to consist of______________________________________ ______________________________________________ I further consent to such other or additional treatment, whether or not described above as may be indicated by reasonably standard and prudent SURGICAL/MEDICAL practices if during the course  of treatment described above unforeseen conditions are discovered or unusual conditions develop. If the use of anesthesia is indicated, I consent to the administration of such anesthetics which may be of surface anesthesia/infiltrate/block local anesthesia/general anesthesia/conscious sedation or any anesthesia as the doctor may deem advisable and proper. I further consent to the taking of photographs and roentgenograms/X-rays sonography, CATscan or my other pathological investigations or my other investigation for the treatment  to be performed, or for SURGICAL/MEDICAL  educational or scientific purposes and the demonstration and publication of such rontgenograms or photographs etc. The nature and purpose of the treatment to be rendered the possible hazards involved and alternative methods of treatments have been fully explained to me and I am free to ask an explanation of treatment. No assurance/guarantee/warranty has been made to me that the results will be to my complete satisfaction although it is believed that the results will be satisfactory. I have not concealed and fully disclosed all material facts regarding the status of my health relevant to SURGICAL/MEDICAL treatment. All  ANESTHESIA /Medical treatment/procedures/operations carry inherent risks. I am advised to consult any other physician/surgeon/doctor before treatment. I consent for taking IV/IM Injection/drugs/tablets/capsules/syrups/or any other medicines prescribed for treatment/Operation.  

                                                                              

(Authorized Signatory.)  

I certify that to the best of my belief treatment/SURGICAL/MEDICAL services have been completed to my satisfaction.  

                                                                              

(Authorized Signatory.)

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