Discharge summary – A strong defence against unfounded allegations

  • Posted on: January 11, 2024

Patients hiding medical history is a big concern for doctors and hospitals. Recording such medical facts that are revealed during investigations is what the healthcare providers must do to shield themselves against allegations of negligence, as this case exemplifies.

The patient underwent surgery for hernia. She experienced pain at the operated site due to pus formation and infection. After about forty-five days, another surgery was performed by the same doctor at the same hospital.

Three months thereafter, a lump formed at the operated site. The patient approached another hospital and underwent yet another surgery for removal of the lump. She was livid at the doctor and first hospital, and sued them both.

It was alleged that the doctor was negligent in performing both the surgeries, which resulted in formation of lump at the operated site.

The doctor rejected patient’s claim and presented his side of the story. It was stated that the patient was diagnosed with incisional hernia in an unknown case of uncontrolled diabetes. She was advised to take proper care to control sugar level and it was clearly explained that if sugar level was not controlled, then there could be post-operative complications.  

The doctor further submitted that during examination it was found that the patient was fully affected from diabetes, her sugar level was extremely high, whereas at the time of admission she did not give information about her diabetes, which is duly recorded in the discharge summary”.

The Consumer Commission carefully considered submissions made by patient and the doctor, and observed the following:

“As per discharge summary, the patient did not disclose about uncontrolled diabetes at the time of admission. This fact proves that she was negligent and ignorant in disclosing her health condition. Another important piece of document is the informed consent for surgery. In this consent form, the risks involved are explained and it was signed by the patient, her husband, the doctor and a witness”.

Carefully prepared discharge summary came to the aid of doctor and hospital as the State Consumer Commission dismissed patient’s case against them.

Source : Order pronounced by Chhattisgarh State Consumer Disputes Redressal Commission on 17th May, 2023.