Chapter: 4.4.2 Types of records

1. Investigation reports

Investigation reports form an important part of patient records. Proper preoperative investigation also can help in proving duty of c-are on part of the doctor. Investigations also help in proving the diagnosis and soundness of the treatment. X-rays, ultra sound pictures, ECG records & histopathological reports are irrefutable proof of proper diagnosis & treatment and hence are extremely important medicolegally.

2. Discharge cards

It is important that discharge summary should always co-relate and mirror the case notes of the patient. The discharge cards should always include the instructions to be followed by the patient after his discharge. Example: how to take care of the wound or a limb which is put in a plaster. It should also include the instructions about the follow up visits and in what circumstances the patients should report to the doctor earlier than the routine follow-up.

It happened in one case where the patients hands was put in a plaster by art orthopedic surgeon and the fingers became oedematous & blue due to swelling of the limb & stoppage of circulation. The patient did not report to the doctor as he was told to come back only after 3 week. Since no clear instructions were given to come earlier in these circumstances the case went against the doctor.

In another case, a patient of medical termination of pregnancy, was asked to report after one month, and she failed to do so. In the mean time the MTP failed and pregnancy continued but the doctor was not held negligent as the patient did not report back on time when she could have been offered repeat MTP.

3. Referral notes

The referral note should always include date & time, patient's general conditions, cause of reference and expected course of action to be followed.

It is always wise to keep duplicate copy of the referral note with patient's signature on the same.

In one case a general practitioner referred a patient of jaundice to better equipped general hospital. The patient went there only after 3 days when his condition had deteriorated considerably. When the patient died the relatives alleged that the patient was referred very late but the duplicate referral note preserved by the doctor helped him in proving his innocence.

Reactions after blood transfusion have led to many mishaps. Here/ preserving blood bank receipts as well as blood bottle labels would help.

In a case where serum hepatitis was alleged to have been caused due to blood transfusion, it could be proved by the blood bottle labels that the blood was checked and was free of serum hepatitis antigen.

Video tapes of endoscopic surgeries, electronic fetal heart monitor charts & continuous ECG, have good evidentiary value, in the court of law.