The importance of medical records in court

Medical negligence 
However, challenges may arise when experts give court different opinions as did happen when a 49-year-old school teacher dragged the Attorney General to court in a case of medical negligence when she developed a fistula after a botched medical operation to remove her uterus.

One expert, a professor of obstetrics and gynaecology, who testified on behalf of the teacher, told court that the surgery carried out on this patient needed to have been carried out by a surgeon of the requisite medical qualification and experience. 

The qualifications and names of the person who carried out the initial surgery were unknown as these were not recorded.

The patient’s operation notes, themselves, were missing.

Evidence adduced 
The professor told court that upon reviewing the patient’s records, he noticed that the records were incomplete, and were poorly maintained by the doctors who attended to her.

A gynaecologist, working in a University, who testified for the Attorney General, told court that the care given to the teacher was the standard care given to any patient in her position, and to him, there was no negligence in this case. 

He told court that having a surgical complication as a result of a medical operation is not synonymous with negligence.

Cross-examination 
During cross-examination, he conceded that there were no medical records in respect of the surgery that the patient had undergone. 

He admitted in court that such records are of prime importance. The two experts agreed that a gynaecologist is the medical expert best suited to carry out a hysterectomy (a surgical operation to remove a uterus).

Both experts were also in agreement that the operation notes ought to have been recorded by the doctor who carried out the surgery.

It was, then, clear to court that the identity of the person who carried out the surgery were unknown as were the qualifications and experience of that person.

Court observations 
Court made the following important observations regarding expert witnesses and their evidence;

(a) Expert evidence presented should be seen to be an independent product of an expert, uninfluenced as to form or content;

(b) An expert witness should provide independent assistance to court by way of an objective, unbiased opinion, in relation to matters within his or her expertise. An expert witness should not assume the role of an attorney or advocate;

(c) An expert witness should state the facts upon which his or her opinion is based. He or she should not omit to consider material facts which could detract from his or her concluded opinion;

(d) An expert should make it clear when a particular question or issue falls outside his or her expertise;

(e) If an expert’s opinion is not properly researched because he or she considers that insufficient data or information is available, then this must be stated, with an indication that the opinion is no more than a provisional one.

Medical records 
To court, medical records are documents that explain all the details about the patient’s history, clinical findings, diagnostic test results, pre and post-operative care, patient’s progress and medication.  

A good record, therefore, serves the best interest of the medical practitioner as well as the patient.

Record keeping serves the useful purpose of proving that the treatment given to a patient or the surgery carried on the patient was done according to established procedure.

The records are the source of truth. They facilitate good care and allow a subsequent caregiver to understand the patient’s condition and are the basis for further investigation and treatment, as they provide a method of communicating with other team members.

The keeping of medical records satisfies legal and ethical obligations as it may be required by medical regulatory authorities and hospitals.

Such medical records, in the view of the court, are the best alibi for medical professionals when sued for malpractice.

In the absence of such records, the alibi is dislodged and the doctor may be found liable.

Court was also of the opinion that failure to document appropriate medical information is a breach of, and a deviation from, the standard of care expected from a medical professional, bearing in mind that the quality of patient care is directly linked to the quality of the medical records maintained. 

It is on record that; “However inconvenient and burdensome it may be to write up medical records accurately, such medical records constitute a vital safeguard for both medical practitioners and patients alike in any situation where it later becomes necessary to conduct any form of investigation as to what transpired during the patient’s treatment”.
   
To be continued

Dr Sylvester Onzivua
Medicine,  Law & You