Dr. R. Asokan has following query.


It is quite clear about the in patient records, but do we have any guidelines for maintaining out patient records. should we keep a copy of the prescription that we issue, if so for how long. what are the other legal requirements in running a private pediatric office practice?


Guidelines for maintenance of medical records is given in Code of Ethics Regulations, 2002 by Medical Council of India and available on their website. 


1.3 Maintenance of medical records:

1.3.1 Every physician shall maintain the medical records pertaining to his / her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India and attached as Appendix 3. [can be downloaded from the website]

1.3.2. If any request is made for medical records either by the patients / authorised attendant or legal authorities involved, the same may be duly acknowledged and documents shall be issued within the period of 72 hours.

1.3.3 A Registered medical practitioner shall maintain a Register of Medical Certificates giving full details of certificates issued. When issuing a medical certificate he / she shall always enter the identification marks of the patient and keep a copy of the certificate. He / She shall not omit to record the signature and/or thumb mark, address and at least one identification mark of the patient on the medical certificates or report. The medical certificate shall be prepared as in Appendix 2.

1.3.4 Efforts shall be made to computerize medical records for quick retrieval.

Gurmit Singh Chaddha has following queries:

1.     For how long a patient has to be kept under observation when admitted before referring to higher centre for further management?

It depends upon the condition of the patient and the facilities available at the treating hospital. As principle, there should be no undue delay in treatment of any patient. Same applies for referral. As soon as a physician thinks that patient requires expert treatment, he should refer it to the higher centre. At the time of referral, care should be taken to provide with proper referral note along with facilities for safe transportation of the patient till it reaches under an expert hand.

2.     How important is it for the patient to mention to the attending doctor that how he has received the injuries?

The importance is same as it is there for proper history in treatment of the patient. It guides the treating physician. In MLC cases, one should take care to record the history given by the patient, as to whatever he says, along with name of the person who gave the history [self or name of the relative etc.]. Physician should try to corroborate the injuries present to the history given as history may not be true in all the cases. If one finds that injuries do not correspond with the history, same should be documented in the case sheet.

3.     What if there is no referral letter provided by the attending doctor who had referred  the patient to higher centre for further management?

The patient should be treated as per his condition; detailed history should be taken from the patient and relatives as to what treatment was given at the earlier centre. They should be asked to get a referral note from the previous centre. All that is known as well as not known should be documented in the case sheet. In MLC cases, if MLC was registered at earlier centre, as evident from the history, it should be informed to the concerned police station. If not, the case should be registered as new MLC with the concerned police station.

4.     How important is ENT consultation in case of nasal injury when a patient is brought  to casualty department, in case MLC is registered?

Treatment modalities do not change whether a case is MLC or non MLC. If a consultation is required in any case, it should be done and documented too.

5.     In case of nasal injury, plugging of cotton swab into nostrils is one of the treatments to stop blood oozing from nose. On which document of the hospital it has to be mentioned if the same treatment was provided or not?

Any treatment provided to the patient in recorded in hospital case sheet under the heading treatment. The same is to be done here too.

A colleague had put up a query: 
What procedure should be followed for shifting of a dead body, person dying in a hospital [both MLC & non MLC case]? Is it necessary that Non -MLC cases should be treated the same as MLC case with regards to shifting to mortuary?

After death of a patient, till the relatives/ next of kin take away the dead body, the body can be shifted to the mortuary. One should maintain a register called as mortuary register. It should bear following columns viz serial no., date, time of keeping the body, place of keeping the body [in cold chamber/ outside cold chamber], room temperature, cold cabinet temperature, place from where body is shifted [ward], name of the deceased, sex, age, address, diagnosis, time of death, kept by whom [if relative, his name in case of keeping the body for longer periods], given to whom, date of giving. When the body is being kept, a receipt should be issued to the next of kin. When the body is to be released, the receipt given at the time of keeping the body should be sought and only then the body handed over to the relative.

          If it’s a MLC case, the nearest police station should be informed about the death and body be shifted to the mortuary. Rest procedure remains the same. If postmortem is to be done at the same hospital, the police shall hand over the dead body to the relatives after the postmortem. In the mortuary register, while handing over the dead body, name and signature of the police constable to whom the body is given should be taken. If body is to be shifted to another authorized centre for postmortem, it should be handed over to the police constable only after getting his acknowledgment. If relatives forcible take away the dead body, nearest police station should be informed and the incident documented in the case file of the patient. It should be remembered that under no circumstance, a body can be forcibly kept in mortuary for non-payment or clearance of medical bills.

A medical officer from Haryana Civil Medical Services has following queries for MLC case

1) Can we do MLC of non serious patient in absence of police personal?

2) Can we do MLC of a non serious patient out side the area of hospital n out the range of police  

    station?

3) Can we do MLC of a non serious patient out side the area of hospital?

            Dear Doctor, the questions put by you are quite vague.

First of all understand what constitutes a medico-legal case. I hope you are able to get answers to all your queries. A medico-legal case is any medical case where the attending doctor, after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies is essential to establish and fix responsibility for the case in accordance with the law of the land. Simply put, it is a medical case with legal implications or a legal case requiring medical expertise. As seen above the attending doctor is solely responsible for labeling a case as medico-legal.

A medico-legal case is received in a hospital in one of the three following ways –

1. Brought by police for examination and reporting,

2. Referred for expert management/advice (medico-legal case already registered at the first hospital which has referred the patient),

3. Suspicion by the doctor after obtaining the history and after thorough examination that the circumstances/findings of the case warrant registration of the case as an MLC. In such a case, the doctor should immediately inform the patient of the same and take his consent for registering the case as an MLC. Consent for such a registration may be refused by the patient and the doctor has no right to force anything on the patient.  The best that should, in his own interest, be done is to carefully document all the findings and inform the nearest police station regarding the same, giving reasons for his actions.

The decision is easy in the first two instances but the doctor has to use his judgment when the person comes on his own and the history is not completely revealed, either by the patient or his relatives/ friends, due to some ulterior motive. When a person has been referred from another hospital, which has already registered a medico-legal case, the same may be informed to the nearest police station; however, a fresh medico-legal case need not be registered. When a patient is to be referred to another hospital for further management, he should be issued a referral letter detailing the treatment given and whether the case was registered as an MLC or not.

Not informing the police of such cases may invite trouble to the doctor under Section 39 CrPC (cases wherein public is duty-bound to inform the police) and Sections 177 & 201, IPC (giving false information & causing disappearance of evidence). However, a doctor is not legally bound to inform the authorities in case of attempted suicide unless the person dies as per Section 202 IPC.

As soon as the doctor agrees to treat a patient, the doctor-patient relationship is established. It then becomes the duty of a doctor to treat the patient. Though every doctor has a right to choose a patient (i.e. he can refuse to treat any patient), as per the Supreme Court Ruling (Parmananda Katara Vs Union of India), no doctor shall refuse to treat a patient in emergency. In the same case, the MCI filed an affidavit stating that “the MCI expects that all registered medical practitioners must attend to the sick and the injured immediately and it is the duty of the medical practitioner to make immediate and timely medical care available to every injured person, whether he is injured in an accident or otherwise…..Life of a person is far more important than the legal formalities.” However, in such cases, the doctor-patient relationship is not established till the patient has been given first-aid treatment and is in a position to give consent for further treatment or medico-legal examination. All legal formalities stand suspended till the patient’s life is out of danger.  The duty of the doctor to provide medical aid, even in MLCs, has been extended to the private doctors also as exemplified by the High Court of Andhra Pradesh in Pattipati Venkaiah Vs State of AP.

A doctor patient relationship is not established when:

o    The doctor treats the patient in emergency situation

o    The doctor makes a pre-employment checkup for a prospective employer

o    The doctor performs checkup for insurance purposes

o    The doctor is appointed by a trial court to examine an accused

o    The doctor examines a person at the request of an attorney for law suit purposes

At this moment, it should be remembered that in a Government set up, a doctor on duty can never refuse to treat a patient giving excuse of his right to choose his patient.

The next important duty is to identify, after carefully analyzing the injuries on the person of the patient, the history given, and the other circumstances of the case; whether the said case falls under the category of an MLC or not.  If it does so, then he must register the case as an MLC and make a serially numbered entry in the medico-legal register maintained in the casualty of every hospital for this purpose. Such an entry should contain the details of the time and date of receiving the case, the time and date of examination and the name of the doctor who has examined the case for easy future reference. The doctor should also intimate the nearest police station of the case without undue delay, preferably in writing and obtain a proper signed acknowledgement. Alternatively, where it is not possible to give written information, the police may also be intimated by telephone. Where the intimation is given orally or on phone, the diary number (DD or the Daily Docket number) should be taken down as proof of intimation and should be properly documented in the patient’s records. Police should also be informed regarding the discharge/death of any patient admitted as a medico-legal case in the hospital.

There is no defined time limit within which a medico-legal case should be registered. Likewise there is no time frame outside which a medico-legal case cannot be registered. An MLC should be registered as soon as a doctor suspects foul play or feels it necessary to inform the police, at any time during treatment. There should not be any unnecessary delay in doing so. A case may be registered as an MLC even if it is brought several days after the incident.

Whenever a medico-legal case is admitted or discharged, the same should be intimated to the nearest police station at the earliest. Necessary entries should be made in the Medico-legal Register of the hospital. This is usually maintained in the casualty of every big hospital. It is the right of a patient to receive the discharge card/referral letter containing the summary of admission, the treatment given in the hospital and the instructions to the patient to be followed after discharge. The hospital cannot deny this right of the patient even if the patient requests for a discharge against medical advice. In such cases, however, mention may be made in the card about the discharge being made on the insistence of the patient and that the patient has been discharged against medical advice.  Failure to provide such a ‘discharge card’ renders the doctor liable for “negligence” and “deficiency of service” as ruled by the Madhya Pradesh Consumer Disputes Redressal Commission in the case of N. K. Kohli Vs Bajaj Nursing Home (1999 (1) CLT 540).

 

If the patient is not serious and can take care of himself, he may be discharged on his own request, after taking in writing from him that he has been explained the possible outcome of such a discharge and that he is going on his own against medical advice. Police have to be informed before the said patient leaves the hospital. Sometimes the patient, registered as a medico-legal case, may abscond from the hospital. Police have to be immediately informed, the moment such an instance comes to the notice of the doctor/ hospital staff.

In case of death of a patient admitted as a medicolegal case,–

1. Inform the police immediately.

2. Send the body to the hospital mortuary for preservation, till the legal formalities are completed and the police releases the body to the lawful heirs.  

3.  Request a medico-legal postmortem examination

4.Do not issue a death certificate – even if the patient was admitted.

The dead body should never be released to the relatives; it should only be handed over to the police or be sent to the hospital morgue, pending the arrival of the police.

A doctor cannot refuse to examine medico-legal cases on the basis of being a private practitioner or citing a jurisdiction problem.

Never delay in examining a medicolegal case or in fact, any other case irrespective of the time of the day or night.

 Preparation and issue of medico-legal reports must never be delayed unnecessarily.