#LegallySpeaking: Medico-Legal Tip
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Tip: "Short forms/abbreviations that are not universally accepted and are capable of being misinterpreted should be avoided by doctors"

• Case Background:
The patient who had met with an accident consulted the orthopaedic surgeon (OP), suffered a fracture in both the bones of his right leg.

• Patient's Allegations:
Due to negligence of the OP, he suffered 15% deformity in his leg and became handicapped.

• Doctor's Defense:
The story made by the patient was false, incorrect and misconceived.

• Court Held:

~ The X-ray was taken on the second visit (after 15 days) and the prescription of the first visit was false.

~ Prescription of first visit 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.

(In this case, OP 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 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.

Source: https://indiankanoon.org/doc/199562121/
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