Time through the ages

By the token of time through the ages Verily man is in loss Except such as have faith, and do righteous deeds, and join together in the mutual teaching of Truth, and of Patience and Constancy

Dr Mohd. Norzi Bin Ghazali MD (UKM), PGDHHSA (London) LLM (Medical Law) Northumbria
Clinical Service Coordinator Director of Clinical Training Centre, Faculty of Medicine,UiTM
Tel: 03-61265011 Fax: 03-51237299 E-mail: mnorzig@yahoo.com

Hospital Serdang 27 th Dec 2010

1 AWARENESS - good medical records - legal requirements

2 ACTIONS TO BE TAKEN - professional - department - organization

3 WHAT DO I DO? - adverse events

* Write what is important * Be honest alteration * Be objective diplomatic language, descriptive, respectful * Be legible sloppy writing is sloppy care, best malpractice defense

Johor Bahru - destroyed by termites Melaka Pontian - Orthopedic case lost because records incomplete : x-rays lost - case taken to court after 20 years, records not available

MEDICAL RECORDS

* Adverse inference * Defense - weight * Case lost

1. IMPLICIT - rolls up their sleeve and allows blood to be taken 2. EXPRESS - when a clear verbal or written consent is given.

NB- there is no absolute requirement for written consent, but it is usual for any major procedure. It provide useful evidence that consent was sought and obtained, but a signature on a form does not of itself constitute consent and the onus remains on the doctor to obtain real and valid consent.

Melaka consent given through a staff nurse who interpret for the Orthopedic Surgeon Patient did not understand

Oral consent is perfectly valid in law but written consent is more usual for major procedures. Written consent can provide documentary evidence that consent has been obtained. A claim may be brought several years after the clinical event, and a judge may prefer a patients evidence to that of a clinical if a signed consent cannot be produced

Alor Setar consent given verbally for speculum examination of 42 year old virgin

The Court held that:

as there was no positive finding that the doctor had recorded his examination of the plaintiff in relation to the color and movements of his toes and that he had found them to be intact, anywhere in the notes and that further when he testified as to the tests he had carried out on the plaintiff he was doing so out of sheer memory after six years, all this pointed more to the possibility that he did not carry them out and which was why he did not suspect something was amiss when the plaintiff complained of pain.
Kathavarayan v Ng Sap Moi & Anor

Contents and depth

Retained placenta? Aseptic technique?

Loss/stolen
Kota Bharu Operation for vaginal repairs Gasping in resuscitation area

Prendergast v Sam & Dee Ltd

(1989) 1 Med LR

MAHKAMAH SESYEN A&E SAMAN NO. 1

18 year old lad Referred by GP for cough, fever and hemoptysis Seen at Casualty Epigastric pain, T=37, throat congested, lungs fairly clear Paracetamol, Benadryl, TCA OPD Patient died about one hour later on the way to private hospital

IM INTRAVENOUS BOLUS SLOW INFUSION DRIP OVER TIME

THOU SHALT NOT USE THE OUA * over-use abbreviation

University of Michigan Doctors abbreviated orders for norfloxacin, an antibiotic, to norflox. In two cases the patients received Norflex, a muscle relaxant. One of the patients was close to psychotic before the error was discovered.

THOU SHALT NOT ALTER AN ENTRY NOR DISGUISE AN ADDITION

Critical events
Tampering with drip set - Labuan Kuching Parkland Formula

* Never go back and alter a record * Recording errors -by a single strike through line that is initialed -Dated -Timed -Identified as error * More extensive errors require more detailed explaination

THOU SHALT NOT USE OFFENSIVE, PERSONAL OR HUMOROUS COMMENTS

* Write the record as though the patient will read it. Example drunk and obnoxious vs ethanol-like odor noted Diabetic ketoacidosis vs alcoholic intoxication * Not to sidestep the truth but to choose language that is descriptive, objective and respectful

Medico - Legal Considerations

Develop a model of practice that considers the adverse potential of particular interventions as well as the benefit. Communicate these to the patient in an appropriate way so that they are involved in decision making. Develop contingencies for the situation where potentially predictable things go wrong and document these in the patient notes.

Medico - Legal Consideration Make good detailed, contemporaneous notes. If necessary make detailed stream of consciousness notes of your seniors interaction with patients, especially when important options are discussed and decisions made

Medico - Legal Considerations

If you are informed of an adverse outcome related to a patient in your care, review the notes as soon as possible, contact your senior for advise. This will ensure that you follow correct procedure and produce an appropriate account of the events related to the episode in question.

Medico - Legal Considerations

If you have to write a statement in relation to a claim, include as much detail as possible. This makes interpretation simpler and can often lead to the situation being rapidly resolved.