Doctor realises the importance of maintaining medical records after being penalized

  • Posted on: December 12, 2017

Recording treatment details is one of the first things that healthcare practitioners must do. While giving care to the patients is their first duty, the law is clear on importance of maintaining and noting observations of the treatment.

Rahman was suffering from excruciating pain in the abdomen. He approached Dr. Martuza who performed a USG of Kidney, Ureter and Bladder (KUB) that reported presence of stones in the ureter. The doctor performed Ureterolithotomy and discharged Rahman after a few days. The unbearable pain in the abdomen returned after about three months and Rahman decided to approach another doctor who diagnosed presence of stones in the ureter. Another surgery was performed after which Rahman got the desired relief from excruciating pain.

Why wasn’t Dr. Martuza able to alleviate him of the pain? Perhaps it was negligence. With this thought in mind, Rahman approached the State Consumer Disputes Redressal Commission, West Bengal. Citing medical records, it was alleged that there was no documentary evidence to prove that the doctor had removed all the stones through Ureterolithotomy. There was no mention whatsoever of the diagnoses, the type and size of the stone in the medical record, added Rahman. It was further alleged that the doctor did not ascertain whether all stones were removed from the ureter or not before discharging the patient. All these facts amounts to negligence, claimed Rahman and rested his case.

The doctor was shell shocked, or so it seemed. It was stated that the patient didn’t have any complain of pain after the surgery for three months. Citing medical literature, the doctor further stated that recurrence of stones in ureter is not unusual. The surgery was performed as per standard protocol and there was no negligence on his part, concluded the doctor.

The Commission wasn’t impressed by the doctor’s defence. It was an open and shut case for them. Making critical observations, the Commission stated the following: “The records of treatment, do not reveal the details of type of surgery in question. There is no documentary proof to prove that at the time of discharge no stone was left in the ureter. The absence of such details indicates probability of leaving stone at the time of surgery. Furthermore, the discharge summary does not reveal any advice for the patient to prevent the recurrence of stone further”.

Dr. Martuza was held negligent and was ordered to pay one lakh as compensation to Rahman.

Source:Order pronounced by State Consumer Disputes Redressal Commission, West Bengal on 24th November, 2017.