Medical record requirmeent of hospitals
nandy
(Querist) 25 April 2016
This query is : Resolved
I have obtained medical records of my mom from a hospital. There is no record of the diagnosis made. A general physician has tried to treat her when she should have been referred to a pulmonologist.
What are the documentation requirements of hospitals? Can the hospital be sued based on improper documentation?
In this case, there is no diagnosis recorded. Treatment procedures have been carried out without any record of clinical parameters which would necessitate such treatment.
Kumar Doab
(Expert) 25 April 2016
A pulmonologist is usually DM (pulmonolgy).
However a doctor MD (Chest) MD (medicine) also treat certain medical disorders e.g. Asthma, AECB, COPD, Ch.bronchitis..........
Ideally Dr. should record the diagnosis.
Dr's start medicines based on clinical observations and later relate with Lab tests and adjust the medicine/dosage.
Expert opinion may be asked for the forum that you may approach. State/national IMA may also intervene.
Hence you may show all record to an able counsel specializing in Medico-legal, consumer matters and understand the merits in complaint.
nandy
(Querist) 26 April 2016
I am trying to understand what are the documentation requirements imposed on hospitals b law/medical council.
1.For example, there is no record of a diagnosis being communicated to patient party. So what are the requirements in terms of communication to patient party?
2.Treatment has been started without any record of clinical parameters that would necessitate such treatment. What are the documentation requirements in this situation?
In summary, is there anything laying down what hospitals should record and provide as medical record to the patient party?
Kumar Doab
(Expert) 26 April 2016
IPD and OPD patients are provided with Dr Rx/ Lab reports, discharge summary.............
You can speak to state/national medical council office bearers, also.
Rajendra K Goyal
(Expert) 28 April 2016
Has the hospital charged for diagnosis and maintained no record / provided no report to the patient?
Have you solid proofs that the doctors did not applied full intelligence to treat the patient.
You should discuss with local lawyer expert in medical negligence cases.
