Notes made during surgery holds a significant importance, not only from perspective of patient care but also from the aspect of healthcare laws. Inconsistencies, irrelevant recordings can raise doubts in a court of law, and adverse inference could also be drawn – as happened in this case.
Irrefutable Facts
A patient suffered from abdominal pain. The doctor performed appendix surgery.
The patient did not regain consciousness and was declared dead. The post mortem report revealed three injuries on the right side of abdomen and presence of pus in it.
Patient’s family sued the doctor, alleging that doctor did not advise fresh investigations and performed the surgery by relying on previous investigation reports.
It was further alleged that the doctor had not provided OT notes regarding details of the surgery performed or the type of anaesthesia administered.
Doctor’s Plea
It was stated that the patient had a history of abdominal pain for last 7 days, for which she had been consulting a number of doctors and thereafter died due to septicaemia.
Court’s Observations
Dismissing doctor’s defence, the court observed from medical records that patient’s medical history of abdominal pain was not noted, fresh pre-surgery investigations were not advised, and OT notes lacked details of the surgery.
Furthermore, medical history recorded by the anaesthetist and doctor was remarkably different and this raised suspicion about the surgery performed.
The court, on perusal of anaesthetist’s notes, noticed that irrelevant facts were mentioned and concluded that the “statement of anaesthetist notes clearly established that the doctor is trying to escape from his liability”.
The doctor was held negligent.
Prevention Is Better Than Cure
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OT notes should be clear, concise, and to the point and should record details of the intervention performed. Any inconsistencies in the OT notes or deviation from the normal is bound to raise suspicions in a court of law.
Source : 15 MLCD (j131) Babubhai Laxmanbhai Parmar v/s Jivan Jyot Charitable Trust & Anr.
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