Medical records means and includes the record pertaining to the admission, diagnosis, treatment, investigation, daily progress, operations, consultations

1. MEDICAL RECORDS
DR. ARIF MASOOD
PRINCIPAL& PROFESSOR
ANANYA COLLEG OF HOMOEOPATHY,
KALOL , GANDHINAGAR

2. DOCTORS AND MEDICAL RECORDS
 Medical records means and includes the record pertaining to
the admission, diagnosis, treatment, investigation, daily
progress, operations, consultations etc.
 Importance of Medical Record
Medical record is required for patients or hospitals.
1. Medical negligence cases
2. For life insurance policy purpose
3. For third party claims under health and accident insurance
4. As a proof of disability
5. Workman’s compensation cases
6. Traffic accidents cases
7. Follow-up cases or taking treatment from another doctor
8. Medico-legal cases

3. MEDICAL RECORDS
 Medical Record is Required for Doctors/
Hospitals for
 1. For medical research
 2. For cost accounting
 3. Hospital audit
 4. Evaluation of drug therapy
 5. Planning
 6. Legal purpose
 7. Administration
 8. Follow-up cases
 9. Insurance claims

4. MEDICAL RECORDS
 What Constitute Medical Record?
 1. OPD cards
 2. IPD cards
 3. Details of provisional and final diagnosis
 4. Treatment record
 5. X-ray films/USG report/CT scan/MRI films
 6. Laboratory reports
 Features
 •The medical record should be adequate, appropriate and
 complete
 • The patient or the representatives have got the right of
 access to their medical record.
 • Well-maintained medical records will help the doctors
 and the hospitals to defend in medical negligence
 cases

5. CONSENT
 Definition
Consent is defined as free and voluntary agreement,
compliance or permission given for a specified act or
purpose.
 • It is based upon the Latin maxim “volenti non fit injuria”
means ‘he who consents cannot complain’. This is
founded on two straightforward factors, firstly every
patient is best judge of his own interest and secondly no
man will consent to what he think is harmful to him.
 • There is no official or codified definition of
consent.Section 90 of IPC defines consent in negative
terms..

6. VALIDITY OF CONSENT
 As per this section, any consent given under the
following five circumstances will not be a true consent.
The consent becomes invalid if given:
 1. By a person under fear of injury or
 2. By a person who is under misconception of the facts
and person who obtains consent knows or has a reason
to believe this or
 3. By an intoxicated person or
 4. By a person who is of unsound mind or
 5. By a person who is below the age of 12 years of age.
 • Section 13 of Indian Contract Act states consent as
“two or more persons are said to consent when they
agree upon the same thing in the same sense”.

7. VALIDITY OF CONSENT
 As per Section 14 of Indian Contract Act, consent is
said to be free and voluntarily when:13
 1. It is not obtained by coercion/force
 2. It is not obtained by fraud
 3. It is not obtained under influence
 4. It is not obtained under influence of intoxication
 5. It is not obtained by misrepresentation
 6. It is not obtained from mistaken subjects
 7. It is not obtained from mentally unsound persons.

8. TYPES OF CONSENT
 Types of Consent
 1. Implied Consent
 2. Expressed – it may be
 a. Oral or verbal
 b. Written.
 Implied Consent
 • Implied consent is common type of consent observed in medical
practice
 • Here the consent is presumed (i.e. implied). For example if a patient
enter in clinic, it is presumed that the patient has came for examination
and consultation. Thus the conduct of patient suggests the willingness to
undergo for medical examination.
 • The consent is not written but legally it is effective
 • The consent is provided for medical examination such as inspection,
palpation and auscultation. It does not cover the consent for examination
of:
 – Private parts
 – Vein puncture or injection
 – Major intervention or operation.

9. TYPES OF CONSENT
 Expressed Consent
 Anything other than implied consent is expressed consent. In
other words, an expressed consent is one, which is stated, in
distinct and explicit language. The expressed consent may be
of following types
 A. Oral (verbal) consent
 – It is consent, which is given verbally. This method is
employed for minor procedures. However, such consent
should be obtained in the presence of a disinterested third
party for example nurse or receptionist
 – Oral consent, when properly witnessed, is of equal validity
that of written consent.
 – Whenever oral consent is taken, it is appropriate to make an
entry in the patient’s clinical record. Such precautions taken
may be of use in future if any action is brought on the doctor
by patient

10. TYPES OF CONSENT
 B. Written Consent
 – Here the consent is obtained in a written
format.The doctor should explain the type of
therapeutic procedure or surgical operation properly
to the patient.
 – Written consent afford documentary evidence
 – When such consent is obtained after explaining
the nature and consequences of the treatment
procedure being contemplated, is called as
informed consent

11. COMPONENTS OF CONSENT
 In medical practice, consent becomes valid when it involves
voluntary-ness, capacity and knowledge.
 1. Voluntariness – It suggest willingness of a patient to
undergo treatment
 2. Capacity – it means degree or ability of a patient to
understand the natur and consequences of treatment offered
 3. Knowledge – it means, sufficient amount of information
about the nature and consequences of disease and/or
treatment has been disclosed to patient.
 Thus, consent should be always:
 1. Free 2. Voluntary 3. Informed
4. Clear 5. Direct 6. Without undue influence/fear
7. Without fraud 8. Without misinterpretation of facts
9. Without threat or compulsion.

12. CONSENT IS NOT REQUIRED
 Consent of the patient or relatives is not required
under following circumstances
 1. Emergency
 2. Notifiable disease
 3. Public interest
 4. Public health
 5. The court order
 6. Prisoner
 7. Immigrants
 8. Medicolegal postmortem examinations
 9. Armed forces, if medical examination is statutory
requirement

13. INVALID CONSENT & CONSENT OF SPOUSE
Invalid Consent
 Consent is not valid when given by
 1. Mentally unsound person
 2. Blanket consent
 3. Consent obtained by fraud, misconception, threat or by force
 4. Consent obtained for criminal activity such as for procuring
criminal abortion, euthanasia etc.
 5. When consent is not voluntary and free.
Consent Of Spouse
Preferably consent of spouse should be taken in following
conditions
 1. Termination of pregnancy
 2. Sterilization
 3. Artificial insemination
 4. Donation of sperm/semen
 5. Any operation that hampers sexual right of the spouse.

14. EUTHANASIA (MERCY KILLING)
 Euthanasia (Eu=good, thanatos=death)
 It means producing painless of a person suffering from
hopeless incurable and painful disease.
 Types-
1.Active Euthanasia
2. Passive Euthanasia
3. Voluntary Euthanasia
4. Involuntary Euthanasia
Earlier no form of Euthanasia was permitted in India, On 9
March 2018 the Supreme Court of India
legalised passive euthanasia by means of the
withdrawal of life support to patients in a permanent
vegetative state

15. EUTHANASIA - TYPES
 1. Active Euthanasia is a positive merciful act, to
end useless suffering. I t is an act of commission eg
by giving lagre doses of drugs
 2. Passive Euthanasia : means discontinuing of life
supporting measures to prolong life. This is an act
omission.Eg; aloowing person to fast till death,
remove of ventillator
 3. Voluntary Euthanasia means at the will of
person. Use of large dose of Opium or other
narcotic drug
 4. Involuntary Euthanasia means against the wil of
the person eg: person in deep coma, severly
defective infant

16. LAW AND CONSENT
 Indian Penal Code (IPC)
 1. Section 87 of IPC – Act not intended and not known to be likely to
cause death or grievous hurt, done by consent.
 2. Section 88 of IPC – Act not intended to cause death, done by consent
in good faith for person’s benefit
 3. Section 89 of IPC – Act done in good faith for benefit of child or insane
person, by consent of guardian
 4. Section 90 of IPC – Consent known to be given under fear or
misconception
 5. Section 92 of IPC – Act done in good faith for benefitConsent and
Medicolegal Cases
 1. For medicolegal autopsies no consent is required
 2. For clinical or pathological autopsy, consent is must
 3. For examination of a victim for medicolegal purpose, consent is
required
 4. For examination of accused for medicolegal purpose, consent can be
obtained. But if the accused is not giving consent then examination can
be done without his consent

17. MEDICAL NEGLIGENCE OR MALPRAXIS
Medical negligence was previously called as
malpractice. Still medical negligence and medical
malpractice (or malpraxis)are used as synonymous
terms but the terms are not same. Medical
malpractice includes other forms of irregular
medical practices including unethical acts i.e. the
medical practice, which is not fair or is a wrong
practice
Medical negligence is defined as want of
reasonable degree of care and skill or willful
negligence on the part of Medical Practitioner while
treating a patient resulting in bodily injury, ill health
or death.

18. MEDICAL NEGLIGENCE
 Thus in the above definition, there are two
important components and for negligence either
one condition has to be proved i.e.
 Firstly – either there is lack of reasonable
degree of care and skill applied by doctor while
treating a patient. The want of care and skill results
in the bodily injury or ill health of a patient or patient
has died due to non-application of reasonable
degree of care and skill.
 Secondly – willful negligence on part of doctor
while treating a patient.

19. CLASIFICATION OF MEDICAL NEGLIGENCE
Negligence is a legal concept, not a medical concept.
Negligence is actionable and an action for negligence
may be brought against doctor in a civil or criminal court.
Thus, negligence can be classified as
 1. Civil negligence
 2. Criminal negligence.
Civil Negligence
 • Negligence is a tort i.e. civil wrong
 • In civil negligence a patient brings charges of
negligence against doctor for monetary compensation
for the damages suffered by him.
 • For civil negligence cases, a patient has to approach
civil court or consumer redressal forum (Consumer
court).

20. CIVIL NEGLIGENCE
 Duty of Care
 • In case of negligence, it is important for patient to
prove that the doctor was duty bound to treat the
patient. In other words, doctor-patient
relationship was already existed and thus the
doctor owes to care the patient.
 Dereliction of Duty
 • Dereliction or breach of duty means failure on part
of doctor to exercise his duty and treat the patient
with due care and skill.
 • Such breech of duty may be an act of commission
or an act of omission.

21. FLOW CHART OF CIVIL NEGLIGENCE

22. CRIMINAL NEGLIGENCE
 Criminal Negligence
 • Here the patient or relatives of patient brings allegation
of criminal negligence against a doctor. In criminal
negligence, the doctor is prosecuted by the police and
charged in a criminal court.
 Criminal negligence is gross negligent acts that had
caused death or severe harm to the patient. The doctor
showed a gross carelessness or gross neglect for the
life and safety of the patient.
 Criminal negligence is a serious than civil negligence.
The negligence amounts to a criminal offense and goes
beyond a mere matter of compensation.21 The doctor is
liable to be punished under the Indian Penal Code
(IPC), example, Section 304-A, 304, 336, 337, 338 etc.

23. CRIMINAL NEGLIGENCE
 Examples of Criminal Negligence
 1. Operation on wrong limb
 2. Removal of wrong organ
 3. Wrong blood transfusion
 4. Leaving instruments in abdomen
 5. Performing criminal abortion

24. DIFFERENCES BETWEEN CIVIL AND CRIMINAL
NEGLIGENCE
Features Civil negligence Criminal negligence
Negligence Absence of care and
skill
Gross carelessness
and disregard for
patient’s life or welfare
Offense No violation of law Violation of criminal
law
Conduct of doctor Compared with peer
group
Not compared to single
test
Consent for act Good defense in court Not a defense
Trail Civil or consumer court Criminal court
Evidence Strong evidence is
sufficient
Guilt should be proved
beyond reasonable
doubt
Punishment Liable to pay damages Imprisonment