How to safeguard Interests (including professional indemnity)

Treat cases which fit in your

  • Qualification
  • Infrastructure
  • Competence and skill

Why? Because legal rule is

  • if you treat beyond the area of qualification, competence and skill then you are negligent per say
  • higher the risk under taken higher degree of qualifications, skill and competence is legally required
  • treating with inadequate infrastructure may amount to deficiency in service except in emergency

Recognize complications and

  1. prevent or treat them as soon as possible yourself, if not possible then
  2. refer to appropriate specialist or
  3. transfer in a well equipped ambulance, preferably accompany patient yourself or rmo
  4. to a hospital/place with better infrastructure to monitor and treat.

Why? Because legal rule is

  1. You are suppose to reduce risks to health of a patient by giving medical care and
  2. You do not guarantee or warrantee cure,that is what is legally required

How to protect rmp in cases of death which are

  1. sudden and unexpected death
  2. Death after a procedure or after surgery or after iv and im injection and
  3. In an expected death where a lot of complications have occurred and huge amount of money is spent in treating them then
    1. if possible call some doctors to see even when you know that they can not do any thing further or help the patient
    2. never ever transfer a dying or dead patient to other hospital
    3. complete your notes and records first to your satisfaction till then
    4. let terminal oxygen, iv ect. Continue till doctors have completed records
    5. you finally declare death, but how ?.

How to declare death?

  1. Ensure your notes and records are complete
  2. Take some relatives in confidence and talk to them about certainty of death. Be tactful and empathetic while declaring death,show genuine sorrow.
  3. ensure that chief / main doctor is present to declare death and do not do through your junior doctor to prevent later on lots of heartaches and headaches.
  4. while declaring death do not irritate them with pending bill, proposed postmortem, information to police, harsh language, arrogance,pointing out relatives negligence,gloat with "that you have done everything"

How to inform police and ask for postmortem?

  1. You need not inform or take consent of relatives for informing police or asking pm. It is the job of police to ask for consent. When the relatives come back from police station they have cooled a bit and are in a requesting mood.
  2. Law does not recognize, if you give death certificate in lieu of patients relatives giving a clean chit of "no negligence" to doctor.

How to protect yourself from black mail of police, pm doctors, local newspapers, local politicians and local goondas

  1. Police-file a written reply rather than oral statement with indoor case papers
  2. pm doctors-meet them with two three of your friends and relatives and if they ask for money then file a complaint with acb
  3. local newspapers-file a case with cjm under s. 499 and 500 ipc
  4. local politician-file a case under s. 383,384 and 506 ipc
  5. local goondas file a case under s. 383,384 and 506 ipc
  6. inform local ima or iap branch and ask them to appoint a three member expert committee and get yourself exonerated medically from problem

How to protect yourself from courts

  1. Receive and reply notices and comply with summons/dates
  2. Seek advice of good medicolegal expert/opinion.
  3. Take medical indemnity insurance for minimum 20 lakhs
  4. Seek expert witness affidavits
  5. Submit eye witness to avert allegations of "was not present during emergency"

Which are the health related insurance sectors which will change the practice of medicine in future

There are two broad areas of insurance sector which will affect the practice of medicine in india.They are-
  1. Mediclaim policies with third party administrators acting as cashless treatment providers to policy holder patients
  2. Medical indemnity and hospital error and omission policy and its variants like comprehensive insurance for doctors covering property, vehicle, indemnity, errors and omissions along with medi-claim

Contract of insurance is also known as insurance policy

  1. Contract of insurance has following elements
  2. Insuredhas to fill a proposal form disclosing all the true facts about insured objective/thing-lifeor non life
  3. Insured pays consideration known as premium in proportion to amount of insurance as per the tariff.
  4. Liability of insurer company arises when the loss occurs to insured due to contingencies described in insurance policy up to insured limit.contract of insurance is known insurance policy,which is the document which regulates the claims to be processed.

What is the basis of insurance?

  1. Basis of insurance is to cover the happening of risk by paying for loss suffered by insured party.
  2. For example-doctors pay for indemnity policy premiums and out of that insurance companies pays to doctors against whom medical negligence claims are decreed.
  3. Law of average of happening of a risk is very rare so insurance companies can afford to disburse claims to those unfortunate doctors against whom claims are decreed by courts.
  4. It is like several people bearing a burden of one unfortunate

What is a risk?

  1. Risk is attached to all the activities of our life and events and living and non living things,however small the nature of it may be. Like a surgeon operating on deviated nasal septum has risk of local anesthetic causing anaphylaxis inspite of test dose
  2. Risk by its nature is an event which is harmful to some one some where,rare but does happen in reality
  3. Risk is an event which is unpredictable chance event.
  4. Risk can be expressed in percentages
  5. It may or it may not happen with the insured person.
  6. If it happens then risk gets converted in damage and brings in action for compensation.

Difference between life and non life insurance

  1. Life insurance products are not pure insurance products
  2. All life insurance products are mixed with investment proposals
  3. Life insurance products are for 5,10,15,20,25 years or even more longer terms and if person survives he gets the sum insured with investment benefits.
  4. If insured dies then survivor nominees get sum insured before maturity

Non life insurances give no returns except when claim arises

  1. In non life products like mediclaim and medical indemnity and similar insurance products require you to pay premium is for one year,which needs to be renewed on yearly basis otherwise continuity lapses.
  2. If any claim arises then insurance company pays otherwise there is no return on premium paid.
  3. Most of us are used to life insurance so when we pay premium we are in habit of asking what do i gain after paying the premium? In non life insurance you don’t get anything except when claim arises on happening of the event.

What is the difference between medi-claim and medical indemnity policy

  1. Mediclaim policy is to cover hospitalization expenses of a sick patient of takes insurance.
  2. Cashless services of mediclaim policy are managed by third party administrators(tpa)
  3. Medical indemnity policy covers claims arising out of medical negligence case against doctors
  4. Hospital error and omission policy covers all errors and omissions of various categories of staff employed by a hospital including medical doctors.
  5. Comprehensive policy for doctors cover in addition to indemnity,errors and omissions covers property,fire, riot,theft and various other perils

What is the role of tpa?

  1. Tpa will empanel the hospitals for cashless services to be provided under mediclaim policy.
  2. Tpa shall sign a separate mou with hospitals.
  3. Tpa are dictating their own charges to hospitals.
  4. If hospital do not agree to their charges prescribed by tpa then those hospitals are not empanelled.
  5. Quality of patient care with low cost will go down
  6. It will have cascading effect on bringing in more medical negligence cases.
  7. Tpa’s will not share burden of compensation granted in medical negligence cases by courts

What does medical indemnity policy cover?

  1. It covers medical negligence claims awarded by courts against doctors
  2. It covers defense cost as per the tariff as prescribed for different courts
  3. Insurance companies have their panel of advocates who are appointed to defend for that specified fees.
  4. Tariff of fees for advocates is so low that good advocates refuse to work for that amount.
  5. Medico-legal experts are not on their panel.
  6. There is lot of red tape and bureaucratic system which frustrates the doctor in trying to take legal assistance from insurance companies.
  7. There is no door step service. There is no 24 hours help line to cover legal emergencies.

Hospital error and omission policy

  1. This policy is for hospitals and nursing homes where number of doctors are visiting
  2. This covers unqualified and unqualified hospital nursing and other staff for specified premium.
  3. It covers professional medical and paramedical staff
  4. It covers all types of errors and omissions by hospital
  5. It also covers medical negligence cases
  6. It does not cover criminal cases
  7. It is not cashless,it has no door step service.
  8. There is no 24 hours help line
  9. One has to choose from prescribed panel of advocates for prescribed fees

HOW VITAL IT IS TO KEEP RECORDS ?

  • If any legal problem arises then properly maintained records are of utmost importance.
  • Records are proof of what one has done actually for his patient.
  • Records are admitted as evidence in court of law as documentary evidence.
  • It is difficult for complainant to rebut record admitted as evidence

WHAT DOES MEDICAL RECORDS INCLUDE ?

  • Out door case paper / register / booklet /card/ letterhead/loose prescription sheet/chit
  • Under treatment certificate/sick certificate / fitness certificate
  • Referral to other doctor /pathology lab/ x-ray /sono / CAT/ MRI

CONSENT RECORDS

  • Record of Informed consent with patient name, name of procedure/surgery/anesthesia, date, place, duly signed and witnesse
    • Is consent required for giving injections / immunization/internal examination like PV examination of breasts and PR ? routinely NO but presence of relative in the room is required, it does not mean the relative has to supervise doctor. Presence of female attendant is must for examination of females.
    • In case of known allergy or hypersensitivity or specific contraindications in patient administration of injections need test dose and consent
      Allergy to egg protein or neurological disorder children may require consent for immunizations.

INDOOR CASE PAPER

  • Chronological order of progress of disease and treatment given
  • Monitoring of vitals, Minimum pulse, BP, RR and Temp. In patients with diabetes monitoring of blood sugar levels, CAD serial ECG’s or continuous monitoring
  • Pathological test, when ordered and what are the positive findings to be recorded on case paper
  • X-Ray, Sonography with report, when ordered and what is the positive finding on case paper

PRE & POST OPERATIVE RECORD

  • Pre invasive procedure or pre-operative treatment or preparation, which is usually aimed at avoiding vagal shock averted by inj Atropine, aspiration during anesthesia averted by NBM, Ranitidine, Inj Metaclopramide
  • Details of invasive procedure or surgery or anesthesia given
  • Post procedure or post operative treatment
    • Date wise record of investigations be it radiological, pathological or reports of CAT or MRI or any other opinion of specialist or consultant
    • Record includes record of refusal of treatment or investigation or surgery

HOW LONG TO MAINTAIN RECORDS

  • Ideally records of adult patients are maintained for 3 years and children, for 21 years. (3+18 years). Mentally retarded forever till the doctor is practicing.
  • From Income tax point of view for seven years.
  • As per code of medical ethics April 2002 for 3 years.

HOW TO DESTROY RECORDS

  • Give a public notice in one English and one vernacular newspaper, with a time limit of usually one month from date of publication in which any one wants the relevant paper can come and take a copy of record needed.
  • After one month destroy record for every one save and except
    • Where litigation is going on
    • Pre-litigation process of notice exchange is going on
    • Mentally ill or retarded patients
    • Where you expect that there could be future trouble.

CAN RECORD BE MAINAINED IN ELECTRONIC FORMAT?

  • Yes, routinely for outdoor patients with one hard copy given to patient.
  • For routine cold outdoor patients also one can maintain electronic record save and except where
    • Frequent monitoring of vitals parameters and investigations are required.
    • Moribund patient,serious patients
    • Patient who develop complications of disease, drug, surgery, anesthesia or procedure
    • Patient which are transferred or referred to other hospitals/doctors
    • Accident /poisoning/ burns /fracture / tetanus and cases involving violence causing disease or injury

HARD COPY, WHAT FOR ?

  • Consent needs to be on hard copy
  • Transfer to other hospital needs hard copy
  • Referral to doctor / investigations need hard copy
  • Police cases need hard copy
  • Certificate of leave / sick certificate /fitness certificate needs hard copy
  • All registers needed by various authorities like birth, death, MTP,PNDT, tubal ligation / vasectomy registers, Indoor admission, Outdoor registers, police information, OT registers, sterilization of registers /autoclave registers/ notifiable disease / Nursing /order book or register, bill books etc need hard copy

KEEP READY BASIC RECORD

  • Some times while proving negligence and deficiency of service records of registration of Nursing home or hospital under nursing home act, shop establishment act, biomedical waste act, MTP act, PNDT act, spirit licence, Narco tic drugs licence are not produced so it becomes corroborative evidence of deficiency of service.

SHOULD RECORDS BE KEPT IN DUPLICATE FOR

  • Outdoor patients, loose sheets of letter heads with signed carbon duplicate retained by doctor or small patient retained page numbered booklets / cards or keep on page numbering the patient retained loose sheet of case paper.
  • CAT, Sono, x-ray, pathological requisitions forms with signature of patient/rep.
  • Patients that are referred to other doctors with signature of patient/rep.
  • Patients that are transferred to other hospitals with signature of patient/rep.
  • Information to police / MLC cases with signature of patient

TO COVER THE EVENTUALITIES OF

  • Patient alleging that he kept on taking treatment to overcome the legal limitation clause for time bar.
  • Some case papers of particular date are not annexed with complaint to suit allegations.
  • Allegations that investigations, referral to doctor, transfer or MLC case registration was not done

THE RIGHT TO RETAIN MEDICAL DOCUMENTS

  • A physician or hospital may retain a photocopy of the document given to the patient Alternately; the patient could be supplied with a photocopy of the document sought while retaining the original with the physician/hospital. A similar approach should be adopted regarding X-ray plates and other information about a patient. A physician/hospital is bound to disclose information when ordered by a court or agencies concerned in the administration of justice. Bombay High court decision in Radhyeshyam Raheja v. Maharastra Medical council that the patient should be supplied with required Xeroxed documents with in reasonable time at reasonable charge.