Short forms/abbreviations - Crying need to standardize
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Short forms/abbreviations - Crying need to standardize
Background:

The patient who had met with an accident consulted the orthopedic surgeon (OP) who applied plaster on his right leg. The patient sued the orthopedic surgeon for negligence later.

Case Points:

- The court found that, in the written defence filed in court by the orthopedic surgeon, he had presented a false prescription stating that he had examined the patient’s X-ray on the first day of consultation but it was proved that X-ray was taken 2 weeks after consultation and treatment was given without examination
- 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." If this would have been questioned in court, it would have added to the problems of the surgeon as it is not a standard short form and cannot be used as evidence in court

Key Learnings:

- Doctors use shortforms in writing medical records and there is nothing wrong in doing so. The problem is that due to absence of standard/accepted shortforms, 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 shortform.)

- A few steps are advisable to be carried out by doctors while preparing their written defense in a case of medical negligence. They are:
1. Collect and recheck all the relevant medical records
2. Ensure that complete facts are stated and every minute aspect is covered

- Check for inconsistencies between medical records and your written defense. (In this case, the orthopedic surgeon (OP) produced a prescription given to the patient during the first consultation in appeal, that is at a very delayed stage of the legal proceedings. Furthermore, this prescription was contradictory with the written defense filed earlier in the court. Obviously, this prescription proved to be counterproductive.)

- 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 accepted medical practice.)


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