Mismanagement of medical records ails healthcare system

This is yet another instance of mismanagement of medical records – a non-procedural aspect of medical practice for which doctor and hospital were held negligent. There were other factors also that went against them, but improper way of making notes and managing medical records was the main reason.

The patient underwent hysterectomy performed by gynecologist at the hospital. Her ureters were injured during the procedure. After discharge, the patient complained of abdominal pain for which medicines were prescribed. But it did not alleviate her suffering.

She visited two or three other hospitals for better management. Eventually percutaneous nephrostomy (PCN) was performed at a hospital by another doctor.

Levelling the blame for complications on the gynecologist and hospital, the patient sued them and made several allegations. One of her main allegation was that an informed consent was not taken from her before performing hysterectomy.

The gynecologist and hospital submitted several statements in defense. Each rebutting the allegations. Their key submissions were two:

1. Some part of medical records were lost
2. Patient suffered from retroperitoneal fibrosis due to which ureters were accidently injured while performing hysterectomy.

The Commission dismissed their defense with following reasoning and statements:

“It is observed that the consent is printed but name as well as address is not filled. The requisite details such as name of operation, anaesthesia, possible complications are not found and further, the consent form is signed by patient and relative but not signed by the treating doctor along with witnesses, if any. This is a blanket consent form, which also does not disclose names of surgeons and anaesthesiologist. Thus, the consent is not informed consent but a printed blanket consent”.

“While perusing the relevant treatment record, the operation notes are not available. In the present case we don’t have the opportunity to know what happened during the laparoscopy operation. Even the video recording is not available. So, there is no evidence to show that the ureters were not damaged during operation. In the absence of any record, their defence cannot be accepted”.

“The doctor has contented that the problems surfaced after laparoscopic hysterectomy operation, due to retro-peritoneal fibrosis – a rare disease. On perusal of written statements filed before State Medical Council, the doctor has accepted that it was complication during surgery, and the injury was accidental. Thus, the concept of ureteric narrowing on both sides due to retroperitoneal fibrosis, is not acceptable and it is an afterthought only”.