How scribbled medical records can cost doctors dearly!

Doctors are generally very busy catering to the clinical needs of their patients. Due to scarcity of time, doctors often find it difficult to write detailed medical records as regards clinical complaints, history, examination, investigations, treatment and follow-ups of their patients. In busy wards and OPDs, the role of writing day-to-day records for patients is often delegated to junior resident doctors. Doctors have also been criticised for their bad hand-writings in the media, and even jokes have been created around this fact. However, the verdict delivered by the Supreme Court of India in the case V. Krishnakumar Vs State of Tamil Nadu & Ors (Civil Appeal no. 4502 of 2010) (judgment delivered in 2015) is sure to take away much of the humor, and bring doctors face to face with the extremely serious consequences of hasty and legally deficient record-keeping.

In this case, the wife of the appellant delivered a premature baby in 29th week of gestation at a government hospital in the year 1996. The weight of the baby was 1250 gm, and the baby was kept in an incubator for 25 days. At the time of birth, the baby was administered 90-100% oxygen and blood transfusion was done one week after birth. During the hospital stay, the baby was under constant care of the doctors in the hospital, which included a Pediatrician. The baby was re-examined by the Pediatrician at 9 weeks and 14 weeks of age, however, the medical records from the hospital-stay and subsequent follow-up visits did not reveal any mention of Retinopathy of Prematurity (ROP) or an examination for the same. Later at the age of 4.5 months, ROP was incidentally detected by another Pediatrician, to whom the baby had been taken for DPT vaccination. What followed was a long journey of medical treatment for the baby, and subsequently a case was filed by the father in National Consumer Disputes Redressal Commission (NCDRC) against the hospital and the doctors. NCDRC awarded a compensation of 5 lakh to the patient. The father of the child filed an appeal in the Supreme Court (SC) for enhancement of compensation.

In the SC, the doctors did try to defend themselves by claiming that they had taken all due care, including the consideration of ROP. However, SC found the hospital and doctors negligent. This particular excerpt from SC judgment should be noted -

["...It was argued on behalf of the respondent that they had taken sufficient precautions, even against ROP by mentioning in the discharge summary as follows: "Mother confident; Informed about alarm signs; (1) to continue breast feeding (2) To attend post natal O.P. on Tuesday.” ...It must, however, be noted that the discharge summary shows that the above writing was in the nature of a scrawl in the corner of the discharge summary and we are in agreement with the finding of the NCDRC that the said remarks are only a hastily written general warning and nothing more....After a stay of 25 days in the hospital, it was for the hospital to give a clear indication as to what was to be done regarding all possible dangers which a baby in these circumstances faces....Respondent No. 3 attended to and examined the baby at his private clinic when the baby was 14-15 weeks and even then did not take any step to investigate into the onset of ROP."]

Thus, the Supreme Court made scathing remarks on the 'hastily written' medical records in the 'nature of a scrawl in the corner of the discharge summary'. The apex court refused to accept the claim of the doctors that they had taken due care as regards ROP, and this was due primarily to the inability of the hospital / doctors to produce any well-documented medical records to support their claim; neither from the hospital discharge summary nor from the subsequent OPD visits. The Supreme Court enhanced the compensation awarded by NCDRC, as follows -

i) Rs. 1,38,00000 to be paid jointly and severally by the hospital and the doctors for future expenditure of the patient, plus

ii) Rs. 48,87,921 along with annual interest of 6% (from the date of filing of the case in NCDRC) be paid jointly and severally by the hospital and the doctors towards the medical expenses borne by the parents.

Thus, the compensation of 5 lakh awarded by NCDRC was enhanced to a humongous 1.80 crores (along with 6% interest on some part of the compensation)!

There is a lot of meaning in the idiom - A stitch in time saves nine. No matter what the hurry, in today's medical practice, doctors should not ignore the importance of accurate medical records, both for admitted patients as well as OPD cases. Without supporting medical records, courts tend to reject the defensive claims made by doctors. And, as is apparent from the above-discussed case, courts draw adverse inference from hastily written medical records.

(This write-up is only a general advisory and not a substitute for qualified legal opinion. Reader discretion is therefore recommended. If you find this write-up useful, please share it with your doctor-friends. TechnoScope Systems is a venture by doctors, for doctors. To know more about how we can assist you, please visit our website. You can write to the author at: