#LegallySpeaking: Medico-Legal Tip
Short forms/abbreviations that are not universally accepted and are capable of being misinterpreted should be avoided by doctors.
The patient who had met with an accident consulted the orthopedic surgeon (OP) who applied plaster on his right leg.
- The court found that, in the written defence filed in court by the orthopedic surgeon earlier, he had stated that on 20.01.2000 when he was consulted for the first time, there was one wound and swelling on the right leg, he had therefore given treatment for reducing swelling and during the next consultation on 05.02.2000, X-ray of the right leg was taken which reported that both the lower part of the bones of right leg were fractured and plaster was done as the swelling was reduced. Subsequently, in appeal, the orthopedic surgeon (OP) produced a prescription dated 20.01.2000 before the court wherein it was recorded that he had examined the patient's X-ray on 20.01.2000. The court observed that from the aforesaid it was clear that the first X-ray was taken on 05.02.2000 and the prescription dated 20.01.2000 was false.
- The court drew adverse inference as the prescription dated 20.01.2000 was devoid of any instruction about the X-ray, details of wounds, fracture of the bones, bleeding points, etc., or instructions about plaster, contrary to the accepted medical practice.
- Doctors use short forms in writing medical records and there is nothing wrong in doing so. The problem is that due to the absence of standard/accepted short forms, these are capable of being misinterpreted or differently interpreted by courts, patients and other doctors. There is a need to standardize commonly used shortforms/abbreviations in medical practice. (In this case, the orthopedic surgeon had recorded "Comp. # B.B. of R Leg," the full form of which is "compound fracture on both bones of the right leg." Luckily, no one questioned whether "B.B" really meant "both bones," otherwise it would have added to the problems of the orthopedic surgeon as it is not a standard short form)
- A prescription must record the history of the patient, detailed description of the wounds, investigations advised, medicines prescribed, precautions advised, and so on. (In this case, the court drew adverse inference against the orthopedic surgeon (OP) for writing a prescription which was devoid of the advice to perform X-ray, details of fracture, and further treatment. The court held that this was against the accepted medical practice.)
Note: The objective of the #LegallySpeaking initiative is to spread awareness about the medicolegal implications of commonly encountered scenarios in a clinician's daily practice.