What Doctors Must Know About Evidence-Based Medical Records Maintenance

  • Skill Level
    intermediate
  • Lectures
    2 Videos
  • Enrolled
    62 students

What you'll learn

It is the primary responsibility of the hospital to maintain and produce patient records on demand by the patient or appropriate judicial bodies. However, it is the primary duty of the treating doctor to see that all the documents with regard to management are written properly and signed. read more »»

An unsigned medical record has no legal validity. The patient or their legal heirs can ask for copies of the treatment records that have to be provided within 72 hours as per the Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. During a trial in the court of law, the witnesses can be served with interrogatories or be subjected to cross-examination.

If the person bringing the record or filing an affidavit in evidence is questioned and he deposes that the record is not in his handwriting and the same was not prepared by him, or that he does not know regarding the patient or the treatment, or that neither the patient nor the attendant narrated the history regarding the health in his presence, and even though may say that the record bears the signatures of the doctors who work there, but it has not worked under any of the doctors under reference to identify their signatures, as his duty is confined only to maintain the record of the patients in the record room, then there may be a difficult situation

Who should attend?

  • All Doctors
  • Physicians
  • Surgeons
  • Nursing Officers
  • Paramedical staff
  • Medical Superintendents
  • Hospital Management
  • Nursing Homes
  • Electronic Medical Record departments of clinical establishments
  • Medical students
  • Indemnity insurer companies

Key concepts covered include:

What you’ll learn

  • How to manage patient care documents while honouring the patient’s right to know.
  • How to discharge the obligation by documentation.
  • How to maintain medical records in a legally sustainable manner.
  • How to avoid penalty or liability by the integration of the recording of events.
  • How to prevent medical malpractice litigation under CPA, 2019, and/or contest it flawlessly, if sued.

Instructor

Mr. Anoop Kumar Kaushal

Advocate, Medical Law, New Delhi


4/5

Mr. Anoop Kumar Kaushal is an Independent Practitioner of Medical Law. He comes with more than 30 years’ journey with Doctors, practicing before the Hon’ble National, State & District Consumer Disputes Redressal Commissions/Forum primarily on Medical Negligence compensation and providing support in Disciplinary proceedings before medical councils, Medical Council of India & High Courts & other statutory authorities.

He specializes in proceedings for Forensic study of the human anatomy, analytical & working litigation experience on fixation of malpractice liability issues wired by the pathophysiology, differential diagnosis, choice of treatment, prognosis, known complications, surgical hazards, anesthetic domains, palliative care. He is also an expert to advice on discharge & follow-up advice, ante-natal to postpartum gestation regimen, morbidities of diseases, admissibility of medical records, and standard medical literature.

For: intermediates

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