#LegallySpeaking: Medico-Legal Tip
Tip: "An Unsigned Medical Record has no legal validity"
Facts of the case below:
• A case of the Complainant (patient):
The 11-year-old patient was admitted to the hospital with a complaint of headache. After numerous trials and tests, no diagnosis could be made. But on the contrary, due to the wrong medication, she lost her eyesight, and her leg amputated due to gangrene developed after the wrong Injection. Thus she claimed compensation of Rs.10 lakhs. (The little one took her last breath during the pendency of the appeal)
• A case of Doctors :
Doctors & Hospitals denied all the allegations. She was admitted to the hospital, as she was not happy with the treatment of earlier hospital. Cause of a headache was Neurocysticercosis (Cysticercal), which is a type of parasitic infection, with Encephalitis and blindness is a known complication of the disease. The patient could survive only because of the treatment.
• Held by National Commission :
There were serious gaps on part of the Hospital in maintaining records. MRI and CT Scan reports were not filed on record. There was no mention of prior treatment in the previous Hospital. Neither the case sheet nor the consent form was filed.
Appellants failed to give any reasons for development Pseudomonas, a common hospital derived infection, as well as medication for this infection, was also not mentioned.
It is the primary responsibility of the treating doctor & hospital to maintain and produce patient records (written properly & signed) on demand by the patient or appropriate judicial bodies. An unsigned medical record has no legal validity. Failure to provide medical records to patients on proper demand will amount to deficiency in service and negligence.
Hon’ble Supreme Court and the National Consumer Commission in various judgments held the hospitals/doctors liable for medical negligence for the non-production of the medical records. The Commission upheld the award of State Commission which saddled damages of Rs.5 lakhs upon Appellants.
First Appeal No. 244 OF 2008 (Against the Order dated 01/04/2008) Complaint No. 46/1998 of the State Commission Delhi